The impact of gender, personality and experience variables on therapeutic responses utilized with hostile and dependent ...

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The impact of gender, personality and experience variables on therapeutic responses utilized with hostile and dependent clients
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Perrotta, Joyceann M., 1957-
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Hostility (Psychology)   ( lcsh )
Dependency (Psychology)   ( lcsh )
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Thesis:
Thesis (Ph D.)--University of Florida, 1989.
Bibliography:
Includes bibliographical references (leaves 163-185).
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by Joyceann M. Perrotta.
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Typescript.
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Vita.

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Full Text











THE IMPACT OF GENDER, PERSONALITY, AND EXPERIENCE
VARIABLES ON THERAPEUTIC RESPONSES UTILIZED WITH
HOSTILE AND DEPENDENT CLIENTS













By

JOYCEANN M. PERROTTA


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1989


























Copyright 1989

by

JoyceAnn M. Perrotta














ACKNOWLEDGMENTS


I would like to take this opportunity to thank those

individuals who have given me their support and

encouragement throughout the process of completing my

dissertation. A special note of gratitude to Dr. Harry

Grater, who was always receptive to exploring an idea, and

whose creative thinking helped to stretch my understanding

of others. His continued enthusiasm for the training

process was communicated to me and enhanced my growth, and

his professional integrity was a valued model during my

years as a graduate student. I would also like to thank

the members of my committee, Drs. Archer, Epting, Nevill,

and Ziller, for the cogent suggestions they provided in the

design and editing of this work. Their varied seminars

were intellectually stimulating, and I benefitted from

their diverse interests and perspectives.

A heartfelt thank you to Drs. Peggy Fong-Beyette, Mary

Fukuyama, James Morgan, and Michael Steinberg and Ms. Kathy

Davis, who assisted in the refinement of the response

alternatives. Similarly, I would like to acknowledge all

the participants in this study who gave willingly of their

time and effort.


iii









I would like to express my sincere gratitude to my

parents for their constant support and encouragement

throughout my years as a graduate student. A very special

thank you to my husband for his continued assistance in

helping me to realize my goals. His unwavering faith in me

has been the single most important force in my life.














TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS.......................... ..............iii

LIST OF TABLES........... ..... ... ................vii

LIST OF FIGURES ...................................... ix

ABSTRACT..................... ..... .. ..

CHAPTERS

I INTRODUCTION .................. .. .. ............ 1

Factors Affecting the Psychotherapeutic
Relationship....................... ... .. ..... 8

II LITERATURE REVIEW.............................. 23

Hostility.................... ................ 23
Therapist Response to Hostile Client Affect.26
Dependency...................... .............38
Therapist Response to Dependent Client
Affect................................. .. .. 43
Facilitative Therapeutic Stance...............48
Empathy as the Common Variable.............. 48
Countertransference.......................... 58
Therapist Personality Characteristics
Associated with Countertransferential
Reactions to Hostile Clients...............66
Therapist Experience Level....................74
Gender Effects...... ........ ..............81
Preference for Therapist Gender.............81
Gender and Empathy....................... 84
Gender and Intervention Style and Outcome...94
Gender and Experience Level................100
Gender and Client Affect.................103
Summary............. ........... .... .* ... .107
Research Hypotheses Stated in Null Form......114

III METHODOLOGY .................. .**. ....... ........ 116

Subjects ................................. .. .116
Instruments ............................... 119










Tape Recordings of Simulated Patients......119
Development of Therapist Response Choices..122
State-Trait Anxiety Inventory (STAI).......126
Buss-Durkee Hostility Inventory (BDHI).....130
Marlowe-Crowne Social Desirability
Scale (M-C SDS)........................ 133
Hogan Empathy Scale (HES).................135
Measure of Emotional Empathy (M-E MEE)......140
The Integrated Scale......................142
Procedure.................... ...............143

IV RESULTS............................. ... ......146

Demographic Data............................146
Findings Related to Hypothesis I and Its
Subhypotheses.................................... 151
Findings Related to Hypothesis II............ 155
Findings Related to Hypothesis III...........159

V DISCUSSION.............. ... ................ 172

Introduction................................ 172
Client Affect................................173
Gender Effects...............................177
Therapist Personality Characteristics........183
Therapist Experience Level.................... 192
Summary and Future Considerations............193

APPENDICES

A PILOT STUDY DATA...............................203

B INFORMED CONSENT STATEMENT ....................205

C QUESTIONNAIRE................................. 207

D TRANSCRIPTS OF VIDEOTAPED ROLE PLAYS...........227

E RESPONSE ALTERNATIVES..........................249

F PERSONAL DATA SHEET..........................261

REFERENCES................................. ........... 263

BIOGRAPHICAL SKETCH.................................. 286














LIST OF TABLES


Page

Table 1 Means, Standard Deviations, and t-ratios
for the Means of Personality and
Experience Variables for Male and
Female Subjects .......................... 147

Table 2 Means, Standard Deviations, and t-ratios
for the Means of Personality and
Experience Variables for Intern and
Preintern Subjects....................... 149


Table 3



Table 4



Table 5


Analysis of Variance Summary for Subject
Personality and Experience Variables
by Educational Program..................... 150

Multivariate Analysis of Variance for
Client Affect, Sex of Client, Sex of
Subject, and Response Style................152

Newman-Keuls Post Hoc Comparison of Means
from Interaction of Variables, Response
Style, and Client Affect.......................154


Multivariate Analysis
Target Involvement,
Client Sex, and Sex


of Variance for
Client Affect,
of Subject............. 156


Newman-Keuls Post Hoc Comparison of Means
for Interaction of Variables, Target
Involvement, Client Sex, and Sex of
Subject ............... ................... 158

Summary of Multiple Regression Analysis of
Independent Variables: Sex of Therapist,
Hostility, Anxiety, Need for Approval,
Emotional Empathy, Cognitive Empathy,
and Experience on the Response Styles in
Relation to the Hostile Clients........... 161


vii


Table 6


Table 7




Table 8










Table 9






Table 10






Table 11



Table 12


Table 13




Table 14


Summary of Multiple Regression Analysis of
Independent Variables: Sex of Therapist,
Hostility, Anxiety, Need for Approval,
Emotional Empathy, Cognitive Empathy,
and Experience on the Response Styles
in Relation to the Dependent Clients......162

Summary of Multiple Regression Analysis of
Independent Variables: Sex of Therapist,
Hostility, Anxiety, Need for Approval,
Emotional Empathy, Cognitive Empathy,
Experience on Empathic Responses of an
Involved and More Generalized Nature......164

Pearson Product-Moment Correlation
Coefficients between the Independent
Variables......................... ........ 166

Cell Means and Standard Deviations of
Criterion Response Styles................ 169

Pearson Product-Moment Correlation
Coefficients between Empathy Variables
and Endorsed Response Styles in
Relation to Hostile Clients............... 170

Analysis of Covariance with Empathy as
the Covariate and Response Style as
the Criterion in Relation to Hostile
Clients....................................171


viii














LIST OF FIGURES


Page

Figure 1 Interaction of Client Affect and
Response Style.............................153

Figure 2 Interaction of Target Involvement,
Client Sex, and Sex of Subject.............157














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE IMPACT OF GENDER, PERSONALITY, AND EXPERIENCE
VARIABLES ON THERAPEUTIC RESPONSES UTILIZED WITH
HOSTILE AND DEPENDENT CLIENTS

By

JoyceAnn M. Perrotta

May, 1989

Chairman: Dr. Harry Grater
Major Department: Psychology

A number of studies conducted during the late 1960s

and early 1970s separately examined various factors thought

to affect response tendencies toward overtly hostile

clients. Since then much has been written about the

influence of the therapist's empathic attributes on the

nature of his therapeutic interactions, but the relative

impact of this variable had not been explored in relation

to hostile clients. The present study attempted to build

upon previous efforts cited in the literature, inclusive of

the empathy variables, seeking to ferret out the

constellation of factors that enhance and those that hinder

facilitative responding with hostile clients. Responses

toward dependent clients were used as a contrast for

comparison, as the dynamics of each client group are seen

as opposite solutions to the same underlying conflict.









The following variables were included in this study:

gender pairing factors, therapist personality levels of

hostility, need for approval, anxiety, affective and

cognitive empathy, and experience with the two client

types. The specific impact of these variables on therapist

endorsement of moving toward (empathic), moving away

(directional changing), and moving against (counter-

aggresive) responses were measured in an analogue study

utilizing structured response alternatives which were rank

ordered according to therapist preference.

The most influential variable on facilitative

responding was the therapist's self-report of empathy.

Affective empathy was positively correlated with

preferential ranking of the moving toward response, while

cognitive empathy was inversely related to empathic

responding and positively correlated with endorsement of

the moving against choice.

Female therapists were shown to deal more directly

with clients than male counselors, who had a higher rate of

withdrawal from clients. Gender pairing seemed to be a

more important variable for male therapists, as they had a

greater difficulty focusing on the current interactional

aspects of the therapy session in opposite sex dyads than

females did.

The impact of prior experience with the

respective client types was found to be negligible.









Suggestions for furthering research in this area were

presented. Similarly, consideration of a training seminar

focused on illumination of countertransferential response

tendencies and role playing appropriate interventions with

hostile and dependent clients was discussed.


xii














CHAPTER I
INTRODUCTION

Philosophical writing concerning the understanding

and managing of hostility has a long history. Such

ancient scholars as Aristotle, Seneca and Plutarch wrote

lengthy treatises on the tendency toward an irascible

disposition and outlined methods for containing one's

anger (Schimmel, 1979). These seminal thinkers believed

that anger was a reactive emotion to a perceived injury

and prompted behavior designed to extract vengeance on the

offenders (Schimmel, 1979). A basic premise underlying

psychoanalytic thought is that conflict over acknowledg-

ment or expression of hostile urges is a prime source of

anxiety in the individual (Freud, 1935). Hostile

exhibitions are common among many character-disordered

individuals, including narcissistic, borderline, anti-

social, and passive-aggressive personalities (Lasky,

1984). Clients who overtly display their animosity abound

and are in need of intervention; however, they are often

identified as difficult clients to treat.

The need for increased understanding and more

effective treatment of the antagonistic client was

evidenced by the devotion of the first issue of The

Psychotherapy Patient (Stern, 1984) to articles on the









abrasive patient. The abrasive patient is described by

Wepman and Donovan (1984) as narcissistically organized,

with a veneer of strength protecting a wounded and fragile

self. This individual pointedly expresses his1 hostility

through devaluing and debasing others. His behavior is

prompted by his ambivalence about intimacy; while desiring

it he is also extremely anxious about the possibility of

rejection and fears a reenactment of past injury through

disappointment and abandonment (Bar-Levav, 1984; Brothers,

1984; Wepman & Donovan, 1984). Consequently, his inter-

actions with the therapist are geared to procure attention

and feed his sense of grandiosity and infallibility while

guarding against communication of his loneliness and need

for nurturance (Bar-Levav, 1984; Wepman & Donovan, 1984).

Characteristically, his attempts to maintain contact are

intrusive, lacking sensitivity to the interpersonal cues

or needs of others. The overbearing demeanor affords the

hostile person a sense of security, however tenuous, and

it does provide him a sense of power; and the relation-

ships that withstand it provides the needed confirmation

of his-self worth and desirability (Bar-Levav, 1984).

The optimal therapeutic strategy to deter this

self-defeating pattern of hostile behavior is to remain

sensitively focused on the fragile self. However, the

iFor reading ease one gender pronoun will be used;
however, unless otherwise stated it should be assumed that
both genders are being referred to (i.e., his should be
read as his/hers).









relentless aggressive behavior can be wearing on a

therapist and result in his self-protective withdrawal

from a patient, or it can offend the clinician to the

point of alienation and stir reciprocal hostile responses

(Rogers & Haigh, 1983; Warner, 1984; Wepman & Donovan,

1984). Antagonistic clients who cannot contain their

anger often direct it toward their therapist, which leaves

the practitioner feeling devalued, uncomfortable, and

having to deal with his own anger at the client for

placing him in such a position (Brown, 1980). Repetitive

hostile encounters designed to maintain distance from the

therapist and defeat the goal of self-exploration and

acceptance can create distress in the clinician and erode

his sense of professional restraint and his ability to

remain facilitative (Wepman, 1984). Surveyed counselors

(Fremont & Anderson, 1986) report a tendency to become

angry with clients who resist treatment through

externalizing responsibility for difficulties and limiting

exploration of topics. While this response appears to be

attenuated by experience, the veteran therapists also

indicated angry reactions when verbally attacked by

clients, and on the whole there was confusion and

discomfort associated with handling such reactions in

therapy. Even the most skilled clinicians have trouble

maintaining an empathic stand toward clients who

consistently malign and attack them as evidenced by Carl









Rogers' transfer of just such a client who was attempting

to figuratively "claw out his vitals" (Rogers & Haigh,

1983, pp. 9-10). Therapists are often driven away by the

intractable nature of the patient's rage, and the

patient's identity as the maltreated, injured party is

strengthened when he perceives rejection from the

humanitarian therapist (Eigen, 1977). The defeat of the

therapist further solidifies the patient's underlying

belief in his own repulsiveness and his fury at not being

able to have his needs met through interpersonal contact,

and thus increases his ire and defensive responding.

The hostile and defensive patient does not fit the

mold of the preferred client which has been described by

the following cluster of attributes: young, attractive,

verbal, intelligent, and successful (Mintz, 1972;

Schofield, 1964). It has been suggested that this

preference reflects the socially condoned characteristics

of therapists who are similarly indoctrinated with this

middle-class value system (Berger & Morrison, 1984). Not

only are they preferred clients, but the educated,

articulate, socially stable middle- and upper-class

patients are the ones who tend to remain in treatment,

while a high premature termination rate is seen with the

more needy and difficult clientele (Garfield, 1978; Heine

& Trosman, 1960).









Therapists are most effective with patients who

exemplify the ideal, those who are motivated to take

responsibility for their desired change and are willing to

trust in the potential benefit of the treatment contracted

for (Wallach & Strupp, 1960). Investigators (Heine, 1962;

Heine & Trosman, 1960; Overall & Aronson, 1963) have found

that it was the congruence of patient and therapist

expectations for treatment that was related to the

continuance of a therapeutic relationship. Having

congruent role definitions allows the client and clinician

to be united in the goal of treatment and to develop a

collaborative alliance. A credible understanding of this

phenomena is offered by Wallach and Strupp (1960). They

state that the client's belief in the therapist's ability

to be helpful fills the caregiver's needs and expectations

concerning his ministering role, prompts a warm

receptivity to the client, and creates a halo effect

concerning treatment. Therapists, like other

professionals, choose their line of work because of the

satisfaction it brings. Deprivation of the counselor's

need to alleviate suffering which occurs with recalcitrant

clients often results in desperate measures wherein

clinical judgment is clouded in the service of regaining a

personal feeling of worth (Brown, 1980; Main, 1957). "The

sufferer who frustrates a keen therapist by failing to









improve is always in danger of meeting primitive human

behavior disguised as treatment" (Main, 1957, p. 129).

The continued applicability of this last statement is

shown in the results of a recent study (Colson, Allen,

Coyne, Dexter, Jehl, Mayer, & Spohn, 1986) of therapists'

responses to difficult patients. Findings highlighted

anger as the predominant countertransferential response of

staff toward highly demanding, hostile, emotionally

labile, and manipulative patients. These authors further

suggested that the treatment personnel routinely

overestimated the strengths and underestimated the ego

deficiencies of these difficult patients and that their

anger sprang from the client's inability to meet the

somewhat unrealistic expectations set forth by the

professionals. Maintaining a collaborative alliance

appears to be more problematic with clients who do not

appreciably respond to the therapist's efforts.

Therapist attitudes appear to be related to both the

process and outcome of therapy. The clinician's attitude

toward his patient influences his diagnosis as well as his

estimate of ego strength, social adjustment, his

flexibility in treatment approach (Wallach & Strupp,

1960), and the client's continuation in therapy (Shapiro,

1974). Berger and Morrison (1984) found that counselors

in training judged an externally motivated and hostile

client to have less potential for change, lower ego









strength, and were pessimistic concerning his ability to

engage in and benefit from therapy when compared with an

equally disturbed but friendlier client. Not surprising-

ly, the harder-to-treat client was also less well liked by

the trainees. These attitudes are also formed early in

the treatment process. Rosenzweig and Falman (1974) found

that therapist ratings following the second treatment

session of felt empathy, positive feelings for, and esti-

mation of, the client's ability to attach in therapy were

related to the client's remaining in therapy. It has been

suggested by Baekeland and Lundwall (1975) that the

client's perception of the clinician's expectations may

result in their functioning as self fulfilling prophecies

and thus contribute to the eventual psychotherapeutic

outcome.

A cynical attitude toward a client is debilitating.

It is logical to assume that little effort is put forth by

the therapist when the expectation is for a low return on

the investment. The more tentative the commitment the

less likely it is that any effective work will be

accomplished. This common sense notion has been

demonstrated empirically via Baekeland and Lundwall's

(1975) review of 35 therapy studies which concluded that

the clinician's boredom, detachment, and dislike of the

patient was consistent with premature termination of

treatment.









The guarded prognostic outlook for treatment with

hostile patients in part reflects that a theoretical

understanding of animosity is not enough to prevent its

presence in psychotherapy from disrupting and derailing

the explorative process. Consistent therapeutic

responding to the abrasive, abusive patient requires much

of the therapist, becoming personally involved to

integrate and be reflective of the patient's outpouring of

rage that will be induced by the threat/invitation to

share his true self in an emotionally intimate

relationship. The current investigation is designed to

build upon previous efforts to isolate factors that

contribute to the maintenance of a facilitative posture

with hostile clients.

Factors Affecting the Psychotherapeutic Relationship

The infancy stage of psychotherapy was characterized

by the practitioner's rigid adherence to the standard

doctrine and procedures set forth by the masters.

Divergence in thought or practice from the espoused dogma

was not tolerated and often resulted in bitter debate,

ostracism, and ultimately the creation of another school

of thought with its followers supporting a new

circumscribed set of beliefs. Along with the growth of

psychotherapeutic application to an increasingly wide

spectrum of human behavior has come a flexibility in

thought and an attempt at integration and utilization of









the concepts of varying ideological camps by the

practitioner. This is evidenced by the increasing number

of therapists who identify themselves as eclectic. In a

survey by Garfield and Kurtz (1976) over half of 855

clinical psychologists contacted stated that they used

procedures and conceptualizations from more than one

school of thought.

The therapist's theoretical affiliation may reflect

his training, his beliefs about human nature, his

understanding of the therapeutic process, and his self-

schemata (Garfield, 1980). However, while theoretical

orientation is associated with a clinician's philosophy of

life, it does not necessarily help in predicting his

intervention style and actual therapy behavior (Garfield,

1980; Strupp, 1978). Consequently, theoretical

orientation is not considered as a viable variable since

helpful therapists are often more alike than dissimilar in

their treatment of patients. The counselor's respect for

others, compassion, and ability to understand another in

order to help him alter the manner in which he unwittingly

stands in his own way, are the hallmarks of a good

therapist (Garfield, 1980; Reisman, 1971; Strupp, 1978).

Experience is another factor that is generally

thought to influence the type and quality of interventions

provided in treatment. The literature reports

contradictory findings concerning how the therapist's









experience level impacts on reported preference of

psychotherapeutic style. Wogan and Norcross (1985)

surveyed 319 professionally affiliated psychotherapists

and found that reports of utilization of psychodynamic

interventions and genuine communication increased with

experience, while reliance on structured technique and

attempts to guide the client decreased with experience.

Therapist experience level did not discriminate among type

of intervention used, amount of control assumed, or

affective distance maintained, according to McNair and

Lorr's (1964) survey of 265 therapists working in

outpatient departments at Veteran's Administration Medical

Centers. Similarly, Wallach and Strupp (1964) reported

that experience level was unrelated to the preferred

degree of distance between client and therapist, therapist

activity level, or flexibility in style in their sample of

more than 300 practitioners. While using large samples

these studies relied upon questionnaire item endorsement

and did not investigate actual or even analogue therapy

behavior. Consequently, it is unclear as to whether it is

actual therapist behavior or simply self-reporting trends

that have changed over the intervening twenty years

between studies.

The variable of therapist experience has been

considered in the literature on response to hostile

clients. A review of the individual studies comprising









this literature reveals that for the most part the

subjects were novice clinicians. Practical considerations

frequently limit the subject pool to available graduate

students with the varying levels of experience being

determined by the number of practice taken, thus, the

possible range of experience is often quite restricted.

There were two studies (Berry, 1970; Haccoun & LaVigueur,

1979) that utilized subjects with a noticeably wider range

of experience; however, the results were less than

compelling. Haccoun and LaVigueur (1979) reported an

experience advantage in the expected direction in terms of

assessing and evaluating angry clients, but it was

uncertain if this advantage extended to therapy inter-

ventions as this analysis was not reported. Berry (1970)

did address this latter point and his study found that

even seasoned practitioners had trouble handling hostile

clients.

Furthermore, client experience has been routinely

treated as a homogeneous variable despite the early

suggestion of researchers in the field (Russell & Snyder,

1963) that the amount of experience with specific client

types and not a general level of client exposure should be

the criterion for categorical grouping of expertise. No

study to date has investigated this factor in relation to

hostile clients. The present undertaking will extend the

findings in this direction with the hope of shedding light









on the equivocal results generally found when the

experience factor is tested.

Freud (1935) recognized that the psychotherapeutic

process was an interpersonal one and that the practi-

tioner's efforts were tempered by his own character

structure and his susceptibility to particular

countertransferential reactions. Due to the repetitive

nature of traits the personality of the therapist has long

been considered to be an important influence on the

interactive relationship with the client (Freud, 1935;

Fromm-Reichmann, 1949; Strupp, 1980a). One personality

characteristic which consistently ranked high in terms of

its impact upon the effectiveness of the doctor-patient

relationship is the therapist's capacity for empathy

(Fromm-Reichmann, 1950; Raskin, 1974; Rogers, 1957, 1961,

1975; Truax & Carkhuff, 1967). Empathy has been defined

as "understanding the world of the client as he sees it"

(Meador & Rogers, 1984, p. 163). Empathy has long been

considered by psychoanalysts (Freud, 1921/1961) and

humanists (Rogers, 1957) alike to be "the core of the

therapeutic attitude" (Emery, 1987, p. 154). The

respective definitions of empathy show a convergence

of thought. Whether it is seen as a curative factor

in itself or as a tool to making more accurate inter-

pretations to benefit the client, the growth in under-

standing of another occurs via a sensitive perception









of his affective state (Chlopan, McCain, Carbonell, &

Hagen, 1985). Kohut's (1984) definition of empathy as

"the capacity to think and feel oneself into the inner

life of another person" (p.82) captures the fluidity of

the process. Truly knowing the client in an empathic

manner requires that the therapist listen attentively,

tolerate uncertainty and resist premature dynamic

formulations, and endure painful and intense emotions

which engender a degree of fragmentation of the self while

being able to regain enough emotional distance from the

client to integrate and process the sensations being

absorbed (Berger, 1984). The therapist must be attuned to

the subtle changes in the feelings evoked in him and call

upon his cognitive faculties of memory and fantasy to

grasp the totality of the other's experiences (Buie,

1981). Nevertheless, a clinician varies in his ability to

be empathic across clients and particular situations and

emotions. Even the most sensitive therapists have

limitations in their responsiveness (Kagan & Schneider,

1987).

Winnicott (1960) stresses that empathy is most

important in the initial stage of therapy when the

counselor functions to establish a "holding environment,"

communicating acceptance of the client and allowing him to

borrow the therapist's strength in the growth process.

Empathic understanding may be a key variable in mediating









countertransference reactions to hostile and dependent

clients. Given the high incidence of premature

termination by difficult clients, it is important to see

if the factors that foster empathic responding in initial

interviews with such clients can be isolated.

The counselor's empathic ability is affected by other

dynamics of the interaction as well as other personality

traits of the therapist. It has been suggested (Hickson,

1985) that clients with more transparent personalities are

easier to empathize with, as the less ambiguous the

stimuli the greater the likelihood of accurate perception

and understanding. Clients can present themselves in an

obscure fashion to prevent being understood. They resist

the temporary vulnerability with another that is necessary

for empathy to occur (Buie, 1981). Patients who are

dependent on others to maintain their level of self-worth

are prone to do this as they distrust others' motivations

and acceptance of them; therefore, they hide clues to

their attitudes and feelings. Buie (1981) further states

that the therapist's ability to empathize is limited in *

part by the scope of his life experience. There must be

some internal frame of reference to understand the cues

being received. The greater the life experience either in

vivo or vicarious, the wider and more differentiated the

range of matching internal referents from which to draw









and the greater the capacity to empathize with a variety

of client experiences.

Actual similarity of client and counselor is thought

to be related to the level of empathic understanding that

the therapist can attain. Kohut (1971) states that "The

reliability of our empathy declines the more dissimilar

the observed is to the observer" (p. 37). Fromm-Reichmann

(1949) also advised that therapists should not work with

personalities too divergent from their own because of the

inherent difficulties in understanding the client's

communications. Likewise, the client needs to be able to

identify with the practitioner in order to interject his

coping skills (Robertiello, 1971). However, excessive

personality similarity between members of the therapeutic

dyad brings the problem of overidentification clouding

perception of the client (Carson & Heine, 1962) and

premature exploration of certain conflicts before the

client has had a chance to develop a rapport and feel

safe with the counselor (Mendelsohn, 1966). Having very

similar personality structures also suggests that the

patient and therapist will have the same unresolved

psychological issues. Exploration of these nonintegrated

emotions may be highly circumscribed in such a pairing

due to a lack of mastery of the area and resulting

countertransferential reactions (Berger, 1984). Lesser

(1961) found that accurate perceptions of client-counselor









similarity were related to the client's feelings of

empathic understanding. Overestimating and

underestimating similarity led, respectively, to projec-

tion and overcompensating behavior which were associated

with low levels of felt empathy in the relationship and

hindered counseling progress. The therapist needs to be

both motivated enough to identify with the client and able

to maintain enough detachment to allow for observation,

comprehension, and response to the unfolding process

(Meares, 1983).

The bulk of the empirical investigations on the

ramifications of personality similarity between client and

counselor were conducted in the 1960s. Reviewing the

literature on personality similarity, Atkinson and Schein

(1986) report a total of 14 such studies published prior

to 1972 with the majority being conducted in vivo at

college counseling centers. An overview of these results

follow.

Carson and Heine (1962) found the predicted

curvilinear relationship between personality similarity

and therapeutic effectiveness in their study comparing

Minnesota Multiphasic Personality Inventory (MMPI)

profiles of counselor and client, and correlating the

similarity with supervisors' ratings of therapy outcome.

Caution must be taken in attempting to generalize from

this study as the sample was composed of senior medical









students on an 18-week psychiatry rotation. The previous

training of these subjects was not mentioned and it is not

certain how similar this group is to novice counselors.

However, further qualified support regarding the influence

of characterological variables is provided by the four

studies of client and therapist similarity measured via

the Myers Briggs Type Indicator (MBTI) (Mendelsohn, 1966;

Mendelsohn & Geller, 1963, 1965, 1967). Mendelsohn and

Geller (1965) were able to support Carson and Heine's

(1962) finding by showing that clients with moderate

personality similarity to their counselors were most

satisfied with their therapy experience. Similarity in

MBTI profiles was also positively correlated with the

client's feeling of being understood by the therapist

(Mendelsohn, 1966). One dynamic that was examined

extensively in these four studies was the relationship

between personality similarity and length of the client's

stay in treatment. Similarity in both personality and

cognitive and perceptual orientation were found to be

positively related to commitment to counseling

(Mendelsohn, 1966; Mendelsohn & Geller, 1963, 1965, 1967).

However, while a high percentage of clients who did not

match their counselor's cognitive and perceptual style

attended only one or two sessions and terminated

prematurely, there was great variability in the length of

counseling when personality similarity was high between









client and counselor. It was noteworthy that these missed

sessions and early terminations in highly similar dyads

occurred early in therapy, most consistently following the

initial interview. The authors concluded that excessive

personality similarity contributes to client ambivalence

about counseling. While it can facilitate communication,

they felt that it also invites a more personal interaction

which may be disquieting to the client and result in

withdrawal from treatment.

A study by Tuma and Gustad (1957) also demonstrated a

positive relationship between client and counselor

similarity on dominance, social presence, and social

participation as measured by the California Personality

Inventory (CPI), and the level of self-exploration reached

by the client in therapy. Other studies have shown that

dissimilarity on the following personality factors within

the dyad is associated with counseling success: original

thinking, vigor, and responsibility (Bare, 1967);

dominance (Swenson, 1967); need for control (Mendelsohn &

Rankin, 1969). Given the mixture of results reported, a

generalized statement about the effects of personality

similarity between client and counselor is appropriate.

Cogent comments require the specification of particular

attributes in question. This study will consider the

impact that client and counselor similarity on the









attributes of hostility and dependency have upon therapist

intervention style.

Theoretical formulations abound concerning the

hypothesized impact of the therapist's own hostile urges,

anxiety level, and need for approval on the client (Adler,

1972; Fromm-Reichmann, 1950; Kohut, 1971; Maltsberger &

Buie, 1974). However, a review of the literature reveals

that these variables have been looked at primarily in

isolation from one another. Keren-Zvi (1980) took a

configurational approach to these and suggested that the

next step may be to include the empathy variable in

attempting to differentiate therapist response tendencies.

The present investigation will take this next step in this

line of research.

Another factor that has been considered to affect the

therapeutic interaction is the gender composition of the

dyad. While past research has shown an overwhelming

preference for male therapists (Boulware & Holmes, 1970;

Chesler, 1971; Fuller, 1963, 1964), this has changed with

therapist preference being related to a client's belief in

the gender's capacity to understand the presenting problem

(Davidson, 1976; Simons & Helms, 1976; Yanico & Hardin,

1985). The outcome studies tend to show a favoring of

female therapists as rated by patients (Fuller, 1963;

Hill, 1975; Howard, Orlinsky, & Hill, 1970; Jones &

Zoppel, 1982). Females are thought to have a greater









capacity for empathy development (Freud, 1925/1961;

Koffka, 1935; Parsons & Bales, 1955). Empirical reviews

of the literature lend credence to this notion (Eisenberg

& Lennon, 1983; Hall, 1978; Hoffman, 1977). It is unclear

if these findings extend to the clinical community as the

three studies reviews (Abramowitz, Abramowitz, & Weitz,

1976; Petro & Hansen, 1977; Sweeney & Cottle, 1976) show

contradictory results. The empathy studies (Dalton, 1983;

Olesker & Baiter, 1972) concerned with gender similarity

of client and counselor are insubstantial in that they

often do not cross client and subject genders, and

generalization to a trained population is questionable

with two of the four studies cited using undergraduates as

subjects.

It has been suggested (Orlinsky & Howard, 1980) that

gender alone may not be a powerful predictor of

therapeutic outcome, but its effect may be increased or

diminished in relation to other variables such as client

diagnosis or therapist experience level. The gender

composition of the dyad is thought to impact on the

response to hostile and dependent affect. The interaction

of gender and the aforementioned affect variables have

been explored but using undergraduates as therapists

(Haccoun, Allen, & Fader, 1976). Studies in this area are

not thorough. The flaws include the following: a res-

ponse to dependency study that used only female clients









(Howard, Orlinsky, & Hill, 1970); only male clients

sampled (Rappoport, 1976); therapists responding to only a

single client (Johnson, 1978); an extremely small sample

size of six therapists (Langberg, 1976). Consequently,

the findings are inconclusive regarding the interaction of

gender, sexual similarity, and hostile and dependent

affect on response style.

One of the primary goals of psychotherapy is to

strengthen the individual's adaptive capacity and increase

self-esteem (Strupp, 1980a). Differences in the

therapist's intervention tendencies toward clients with

two contrasting restrictive behavioral styles is the focus

of the present study. Hostile and dependent clients were

chosen because, while the presenting behavior patterns are

polar opposites, they are each defensive solutions to an

underlying sense of vulnerability and fear (Horney, 1950).

Feelings of helplessness are overt in primarily dependent

persons and primary but repressed in hostile clients,

while the reverse is true of anger in these types. The

extremes of either of these affects can be difficult for

counselors to respond to in a therapeutic manner. The

differential response tendencies of therapists will be

considered in relation to the following factors: client

affect; gender pairings; experience levels; therapist

personality.









The literature review that follows briefly considers

the theoretical underpinning of hostility and dependency

and a general understanding of countertransference.

Frequent therapist response styles and appropriate

strategies are discussed in reference to hostility and

dependency. Empirical studies concerning client hostility

and dependency and the relevant findings are examined.

The contribution of a number of factors such as gender

pairing, experience level, and personality characteristics

of the therapist to the clinician's interventions style is

under consideration. Are these the factors to which

Winnicott (1949) refers when he suggests that it is the

maturity and emotional stability of the practitioner that

determines his response despite similar sentiments

elicited by certain patients in a wide variety of

therapists? The central question to be answered is: In

what way does the gender composition of the dyad, the

previous exposure to the respective client types, and the

therapist's empathic capacity in conjunction with his

anxiety, hostility, and need for approval impact upon his

treatment of hostile as opposed to dependent clients? The

study is designed to further the response to this question

and obtain clues to making therapy with hostile patients a

more stimulating and productive learning experience.













CHAPTER II
REVIEW OF THE LITERATURE

Hostility

Webster (1980) defines hostility as a feeling or

expression of enmity, ill will, unfriendliness, and

antagonism. While hostility is defined by Buss (1961) as

a predisposition to evaluate people and events in a

negative fashion, it is considered to be an enduring

attitude that has the characteristics of a trait (Keren-

Zvi, 1980). Different writers have theorized as to the

cause of animosity in others. Homey (1950) has stated

that hostility arises in response to the perception of an

unfair frustration. She states that the accompanying

feelings of helplessness and hopelessness in the face of

maltreatment trigger enmity which decreases with a

corresponding increase in assumption of responsibility for

the interaction and the perception of effectiveness.

The notion that deprivation leads to animosity was put

forth by Harry Stack Sullivan (1965) when he hypothesized

the child's first experience of loss through weaning may

result in an aggressive hostility. He also commented on

his observation that rage is often expressed when a person

experiences terror, noting for example the infant's

rageful response when physical restraint interferes with









breathing. Layden (1977) further documents the occurrence

of this behavior in the animal kingdom. Taking an evolu-

tionary viewpoint he sees hostility as having developed to

allow assumption of a position of superiority and thus

ensure self-preservation. Echoing the connection of

deprivation to animosity he states that the curtailment

of biological need fulfillment leads to a deficiency in

respect that results in feelings of inferiority. Both

Layden and Homey are in agreement that "inferiority

generates hostility" (Layden, 1977, p. 6).

Homey (1945) has theorized that hostility festers

if not expressed and results in anxiety and feelings of

inferiority. She states that anxiety is caused by

"feelings of helplessness and isolation in a world

considered to be potentially hostile" (Horney, 1950,

p. 297). Sullivan (1953) also makes the connection

between anxiety and hostility, as he suggests that anger

is expressed in order to allay the experience of anxiety.

The two emotions tend to feed upon and reinforce each

other, with the high level of fear providing self-

justification for hostile reactions (Horney, 1937).

Homey (1950) further hypothesizes that fear of

rejection is the particular insecurity that underlies

hostility. According to her, an entrenched self-belief

that they are unlovable generates anxiety concerning

rebuff and, consequently, an antagonistic position is









adopted to protect against further erosion of the fragile

self. Feeling defenseless, the hostile person lives out

the phrase, "the best defense is a strong offense," in

their interpersonal interchanges. The externalization of

the self-loathing and envy results in enmity and feelings

of superiority. The combination of the underlying fear

and narcissistic orientation prompts the abrasive person

to think of himself as the injured party (Bar-Levav, 1984;

Wepman & Donovan, 1984).

Homey (1945) speaks about the aggressive person

whose neurotic solution to fear is the hostile, intimi-

dating stance and whose world view is. constricted to

seeing only the ill will of others. Thus, an attitude

of entitlement and self-righteousness often accompanies

their anger. She stresses that these individuals seek

success and recognition to affirm their strength and

fortify a fragile self-esteem and generate a sense of

self-sufficiency. They deny failure as they dread

humiliation and are motivated to protect their sense of

pride aggressively, not refraining from degrading and

embarrassing the perceived threatening object (Horney,

1950). They are unable to directly admit or express

dependency needs or tenderness for fear that such

vulnerabilities would be exploited by a malevolent world.

Sullivan (1953) reiterates this theme when commenting

on malevolence in children. He states that a hostile









countenance is born out of repetitive inconsistent and

anxiety-provoking responses to requests for affection and

tenderness by important caregivers that promote the

association of pain and rebuff to expressed need for

emotional sustenance. A person so treated does not feel

worth or have self-respect. He develops an extreme

sensitivity to personal slights and does not anticipate

respectful and considerate treatment from others (Layden,

1977; Sullivan, 1953). Wepman and Donovan (1984) simi-

larly state that ambivalence about allowing oneself to

receive nurturance underlies a person's abrasiveness.

Their intrusiveness is seen as an aggressive attempt to

interact with others from a position that affords a sense

of power while maintaining enough distance that they will

not have to contend with the threat of intimacy. Kernberg

(1975) also ties together parental coldness and vengeance

with the adoption of an arrogant and grandiose style by

narcissists to defend against overwhelming perceptions of

other produced rage. Taking the individual's perspective

then, hostile behavior is seen as legitimate and necessary

behavior within the context of a Darwinian fight for

survival in a menacing environment (Horney, 1945).

Therapist Response to Hostile Client Affect

Therapists' needs to be able to comfortably explore

hostility as its direct and indirect expressions, in the

form of anxiety and self-devaluation, underlie many of the









difficulties for which clients seek therapy (Faries,

1958). Hostility is uniformly present in the transference

of psychotic and borderline patients (Adler, 1970).

Drawing upon her extensive experience with psychotic

patients, Fromm-Reichmann (1942) attributed the etiology

of many severe disorders to the individual's fear of his

own and others' hostility. She pointed out that the

culture was engendering conflict by promoting an

antagonistic competitiveness while being founded on a

moral bedrock of Christian charity to others. She further

surmised that attempts to adhere to these antithetical

societal mandates resulted in inadequately suppressed

animosity that sur- faced as neurotic, psychotic and

psychosomatic disorders. Particular examples she offered

included: agoraphobia--which she saw as fear of

aggressive retaliation for unconscious animosity,

unconscious hostility presenting as melancholia, and

migraine headaches formulated as expres- sions of

repressed hostility (Fromm-Reichmann, 1954).

In work with depressed and suicidal patients,

hostility often presents itself in the form of a hostile-

dependent relationship. Bloom (1967) investigated the

suicides of six patients at a training center and found

that the irritating, demanding, and hostile patients

evoked countertransferential hostility in the therapist.

The therapist attempted to suppress this response and this









denial resulted in a lack of awareness of the patients'

enmity and the strength of their destructive urges, as

well as an unconscious denial of protection of the client

at a critical point in therapy. In each case the

therapist was defensive about countertransferential

hostility, and the suicide occurred within two weeks of a

perceived rejection by the therapist. The therapists had

moved away from and become less available to these hostile

patients both physically, through a decrease in the

frequency of sessions, and emotionally, through a with-

drawal of involvement which was represented by a lack of

exploration of the transference. Alexander (1977) also

commented on the therapist's need to be aware of his

hostility toward the suicidal patient, stating that denial

of resentment can build to feelings of exploitation and

result in a detachment from the client and his true

emotional state.

Theoretically, it is believed that hostility results

from narcissistic wounding and reflects an underlying

sense of deprivation and envy which is expressed in

contempt for the satisfaction of others (Buie, Meissner,

Rizzuto, & Sashin, 1983). It has also been suggested that

many therapists experience their client's hostility as a

narcissistic wound to their own image as a healer and that

therapists with unresolved issues about their own anger

and destructive impulses react defensively to client









hostility as opposed to reacting therapeutically (Faries,

1958; Formento, 1980). If the therapist is uncomfortable

with his own hostile urges, he often reacts punitively,

withdrawing from or attacking the patient for making him

aware of his own angry feelings (Nadelson, 1977). The

tendency is to attempt to control the patient's hate and

destructiveness because they call forth recognition of

these same unsavory characteristics in the therapist,

which threatens the therapist's idealized image of himself

as a rational, objective person who has achieved great

control of his impulses (Epstein, 1977). The counselor

often tends to become directive and content-focused in the

face of client hostility. It is hypothesized that this

occurs because of the counselor's fear of the

ramifications of the exploration of a personally

threatening issue (Hector, Davis, Denton, Hayes, Patton-

Crowder, & Hinkle, 1981). It is further postulated that

even if the therapist can control his overt response to

the client's hostility, his negative response will be

communicated unconsciously and result in mutual rejection

between therapist and client (Epstein, 1977).

Inability to maintain a therapeutic stance is also

evidenced by a loss of cognitive flexibility in attempting

to understand a patient's antagonism. Adler (1970) states

that the patient's hostility in therapy may spring from

any of the following motivational sources: the expression









of a rage reaction due to an anticipated rejection by the

therapist; the concealment of more threatening wishes for

nurturance; the devaluation of the therapist, which is

designed to undercut the impact of the therapist's anger

should it be projected onto the client; and a reenactment

in the transference of earlier perceived parental devalu-

ation. Often, only one of these possible motivational

sources is considered in attempting to understand the

patient's animosity. The patient's hostility is

frequently seen as a defense against recognition of his

dependency needs, and the practitioner then focuses on the

presumed underlying needs without adequate investigation

of the patient's more overt feelings (Eigen, 1979). While

this serves to make the client's demeanor more palatable

to the counselor and allows for the retention of a warm

and nurturing stance, the relationship is based on an

illusion. Consequently, the counselor is not being

genuine and the client is denied the experience of being

truly known and understood.

Curtis (1982) considers the constructive channeling

of hostility to be a key issue in therapy, one which often

determines the overall success of treatment. He suggests

that ineffective management of animosity in therapy often

results in both further decompensation and premature

termination of clients. Given the prevalence of hostility

conflicts in therapy, it is important to pinpoint the









factors that interfere with the therapeutic exploration

of animosity. Managing the antagonistic client is a

complicated endeavor. While the therapist must remain

empathic in his approach, benign understanding is not

necessarily helpful as the therapist is often perceived as

weak and rendered impotent by the client. The practi-

tioner needs to demonstrate to the client that he is

capable of managing the effects of the client's anger

towards him, that while he acknowledges the client's anger

it will not cause him to reject the client or retaliate in

kind, nor will it frighten or destroy the therapist.

Reacting defensively to the client's hostility increases

the power of his anger and serves to perpetuate and

solidify the interpersonal style that the client is

currently limited to. The therapist needs to establish a

dominant position in the relationship in order to engage

the hostile client in therapy. Bonime (1976) speaks to

this issue when he underscores the necessity of the

therapist's responding in an empathic but firm manner to

the hostile client. An empirical study by Crowder (1972)

also found that submissive countertransferential reactions

had a greater negative impact on the therapeutic outcome

than dominant countertransferential reactions.

Winnicott (1949) views the eliciting of hostility in

others as part of the maturational process to being able

to accept love from others. The client needs to









experience reactions to both his negative and positive

qualities in order to integrate them into his self-

concept. The therapist who responds genuinely to only the

client's more positive attributes encourages splitting and

does not promote processing the underlying conflict

embedded in the ambivalence which the coexistence of love

and hate toward significant objects entails (Poggi &

Ganzarian, 1983). The client's acceptance and integration

of feelings of both love and hate towards another reduces

his fear of the destructive power of his rage (Spotnitz,

1976), specifically diminishing the fear that the more

positive aspects of his personality will be overwhelmed

and eradicated by it (Racker, 1957). The greater the

client's perceived discrepancy between the therapist's

positive, accepting qualities and his own anger and self-

involvement, the more the client experiences his own

"badness." This intolerable distribution of badness

results in a greater need to defend against such

awareness, and thus the client's reality testing is

further compromised and he is further entrenched in the

projection of his own rage (Epstein, 1977). Winnicott

(1949) suggests that the therapist should share with his

client the negative feelings that have been aroused in him

by the client, as the client will trust the credibility of

the therapist's communication of care and positive affect

only if he has experienced his hostile reactions as well.









Being appraised of the impact that expressions of

hostility have upon the therapist allows the client to

learn reasonable limits to such expressions beyond which

relationships are damaged and the client would reexperi-

ence feelings of abandonment and rage (Epstein, 1977;

Racker, 1957; Spotnitz, 1976).

While it is helpful to share with the client the

impact of his behavior on others, in order for him to

incorporate and benefit from this knowledge this

communication must be therapeutically, as opposed to

antagonistically, motivated. Greenson (1967) suggests

that the therapist needs to be able to absorb the hostile

attacks of his patient, sharing with the patient only as

much of its impact as the patient can tolerate knowing.

Lashing out and attacking the client in kind is not

beneficial, as it will result in further combatitive

behavior. Harsh feedback triggers anxiety and feelings of

inadequacy, with the resultant externalization of self-

loathing in response to the perceived criticism. It is

believed that while anger may be a basis for a sense of

self, the hostile client also fears the destructive

potential of his anger and will terminate therapy

prematurely if he perceives that the therapist is

incapable of helping him understand and moderate it.

Crowder (1972) lends some empirical support to this

hypothesis. He reported that while successful therapists









tended to be rated as more hostile-competitive with

clients early in therapy, they resolved this

countertransferential difficulty and assumed a

supportive-interpretive stance as therapy progressed.

The unsuccessful therapists did not resolve their

countertransference; they were significantly more

hostile-competitive and passive-resistant in their

behavior in treatment than the successful practitioners.

It has been shown that therapists interact

differently with various types of client because of the

interpersonal invitations offered by the client. In an

analogue study using trained actors Heller, Myers, and

Kline (1963) found that therapists responded to the

affective pull of their clients in a set fashion.

Specifically, these authors reported that, according to

ratings of taped sessions, hostile client behavior led to

reciprocal hostile behavior on the part of the therapist,

while friendly client behavior evoked friendly, agreeable

responses from the therapist. These authors commented

that their study highlighted a group reaction, an

objective countertransferential tendency, toward the

hostile client and did not focus upon the different

reactions related to personality idiosyncracies of the

therapists. Gamsky and Farwell (1967) reported similar

findings in an analogue study with thirty school

counselors who interviewed both friendly and hostile









clients. The counselors responded with avoidance and

counterhostility to the hostile clients, while they

reacted positively with approval and requests for

elaboration in conjunction with the friendly clients.

The results of the Mueller and Dilling (1968) study lend

further support to the idea that client affect invites and

often receives reciprocal responses that are not neces-

sarily therapeutic. These authors reviewed actual therapy

sessions and found that the client's hostile-competitive

behavior towards the therapist was significantly and

positively correlated with similar behavior by the

therapist, while support-seeking client behavior was

correlated with supportive-interpretive responses by the

therapist.

Responding in a complimentary manner, defined as a

high probability response, to the client's invitations

does not necessarily facilitate therapeutic movement. The

results of Dietzel and Abeles' (1975) therapy outcome

study showed that low therapist-client complementarity

during the middle therapy sessions was predictive of

successful therapy, as judged by decreased pathology on

MMPI profiles. This finding supports the theoretical

ideation endorsed by Sullivan (1953), Haley (1963),

and Carson (1969) that it is the disconfirming and

noncomplementary response of the therapist that is

conducive to effective therapy. As Havens (1976)









explains, it is the therapist's violation of the patient's

expectations, which he refers to as counterprojection,

that forces the client to step outside his limited and

neurotic interactional pattern and accounts for growth in

therapy. The therapist needs to engage in counter-

projective behavior from the beginning of therapy, as it

has been shown that the boundaries of the therapeutic

interaction become established early in therapy, often

within the first three sessions (Strupp, 1980b).

The therapeutic interaction is a reciprocal process,

and the therapist's response has been shown to influence

the client's communications. The first study to

investigate the effect of the therapist's response to the

client's hostility was conducted by Bandura, Lipsher, and

Miller (1960). These authors coded actual therapy

sessions and found a significant and positive correlation

between the therapist's approach to the client's hostility

and the client's continued exploration of the issue.

Similarly, Varble (1968) analyzed sessions over the course

of therapy for 16 clients involving 13 therapists and

found that clients continued to express their feelings of

hostility if the therapist approached it, but discontinued

such exploration if the therapist avoided the hostile

affect. Conflictual material needs to be addressed in

order to be resolved, therefore, the therapist should

approach negative affect and invite continued exploration









of it when it appears in therapy. This study showed that

approach by the therapist did not inadvertently reinforce

expression of hostility in therapy, as it was found that

the frequency of the client's initiation of expressed

hostility decreased over time in therapy.

Hostility in therapy can be further subdivided into

hostility directed at the therapist and hostility directed

at objects outside of the therapeutic situation. Bandura,

Lipsher, and Miller (1960) investigated the differential

impact of these two variables on the therapist's response

tendency. They found that therapists were more likely to

respond facilitatively to antagonism directed at others as

opposed to hostility directed at them personally. Varble

(1968) replicated this finding and extended it by showing

that increasing experience did not necessarily alter the

therapist's response tendencies. He compared staff

psychologists with an average of seven years experience to

interns with two years experience and found that while the

staff approached their clients' expressions of other-

directed hostility slightly more than the interns, the

reverse was found for therapist-directed hostility. The

author commented that the higher level of approach to

therapist-directed hostility shown by the interns may have

been influenced by a seminar on countertransference they

were attending while the study was taking place.

Consequently, the generalizability of this finding is









questionable. The relationship between therapist

experience and response to the direction of client

hostility was also investigated by Gamsky and Farwell

(1966). The results supported Bandura's finding that

therapists are more inclined to be facilitative in

response to other-directed animosity, but unlike the

previous study the experience variable proved to be

significant for therapist-directed hostility. The more

experienced counselors approached therapist-directed

hostility more than the less experienced subjects. It is

possible that the contradictory findings concerning the

impact of level of experience on therapist response to

antagonism may reflect differences in the type of

experience the subjects have had. The amount of overall

therapy experience does not reflect the amount of

experience the therapist has had with particular client

types.

Dependency

The dependent personality has been described as

feeling weak, helpless, and inferior with a need to rely

on others to nurture and protect him from experiencing the

intensity of his vulnerabilities and insecurities (Fromm,

1947). Riddled with feelings of inadequacy, a sense of

insubstantialness pervades this characterologically

disordered individual who fears the assumption of

responsibility due to an underlying self-concept of









incompetency. Believing he is ill equipped to meet the

challenge of the world alone, this personality identifies

with and emotionally clings to a strong and supportive

figure (Millon, 1981). Homey (1945) speaks about the

essential self-abasing characteristics of the dependent

personality, whom she refers to as invoking an inter-

personal style marked by compliance which is geared to

obtain gratification of both approval and affection

needs and maintenance of the individual's other-directed

self-esteem needs. The level of self-esteem fluctuates in

accord with the level of approval and support received

from significant others (Chodoff, 1972).

The dependent individual is marked by a submissive

stance and a chameleon quality in attempting to mold the

self to be more pleasing to others, and thus maintain a

tenuous sense of security (Millon, 1981). Dependent

individuals do not maintain a consistent sense of self;

they rely on others to shape their identity and give them

substance (Birtchnell, 1984). Assertive demands for

respect are missing, due to the individual's perception of

inferior status. It is postulated that the excessive

submissiveness exhibited by the dependent personality is

the superego's response to strong feelings of hostility

and opposition to parental figures (Birtchnell, 1984).

Hostile urges are repressed, due to a belief that such

expressions may tax the relationship and jeopardize









security through loss of the depended upon figure (Millon,

1981). The dependent personality denies anger when

experiencing rejection for fear that exposure of

dissatisfaction will result in a more complete rejection

(McCranie & Bass, 1984). Consequently, while highly

self-critical, the individual adopts a naive, optimistic

view of relationships to avoid recognition of areas of

inconsistency, dissension, or disharmony and to maintain

the magical belief that the stronger other can always

right things (Abraham, 1924/1927; Millon, 1981).

Deficiencies in the quality of the early attachment

relationship between caregiver and infant have been shown

to be predictive of excessive dependency behavior in

preschool children (Sroufe, Fox, & Pancack, 1983).

Inconsistency in response to the infant's emotional

arousal is thought to be a key factor in compromising his

capacity for autonomous functioning (Ainsworth, 1972;

Sroufe & Waters, 1977). The infant that is not comforted

or encouraged in times of distress becomes overwhelmed by

his affect and learns that he cannot rely on the world to

help him master challenges, and thus comes to fear new

experiences.

Certain parenting styles have been linked to the

development of excessive dependency in children. Bowlby

(1977) cites the following as pathogenic parenting styles:

persistent indifference or rejection of the child's









request for nurturance; utilization of threats of

abandonment or discontinuation of love as a way to

triangulate or discipline the child; threats of spousal

desertion, homicide, or suicide that establish the

fragility of the family unit; and making the continuity of

the family contingent on the child's behavior, and thus

inducing guilt with each threat of disruption. The

following perceived maternal characteristics have been

shown to correlate with dependency in young women: mother

as the more influential parent, emphasizing conformity as

opposed to achievement, and mother's strict and

controlling child rearing style (MCranie & Bass, 1984).

Dependent individuals are anxious about separation and

terrified of abandonment, as they see themselves as

helpless and inadequate people who cannot trust their own

judgment and decision making skills. They attempt to

counter these fears through merger with another. They

often become compulsive caregivers to maintain others

close to them and thereby meet their own nurturance needs.

Dependent persons have not been able to complete the

separation-individuation process; they remain anxiously

attached to significant figures, fearing that separation

will result in rejection and being overwhelmed by

environmental demands (Bowlby, 1977). Insecure

attachments predispose an individual to restrict his

interaction with the world, circumscribing his









explorations because of a fear of defeat and humiliation

without the aid of his stronger partner.

The literature frequently links dependency and

depression. Dependent individuals appear to be prone to

depression (Birtchnell & Kennard, 1983; Chodoff, 1972;

Fenichel, 1945; Millon, 1981). Present research on both

clinical and nonclinical populations (Blatt, Quinlan,

Chevron, McDonald, & Zurdoff, 1982) suggests that feelings

of helplessness and dependency may represent an

unarticulated characterological depression. These authors

report a positive correlation between dependency and the

following depressive attributes: impulsive behavior;

rumination about possible abandonment; suicidal gestures.

The dependent personality experiences depression when

constant reasurrance that they are loved is not

forthcoming (Bibring, 1953; Blatt, 1974). Birtchnell

(1984) contends that the tendency to rely upon the

external support and approval of others to maintain

self-esteem is the link between dependency and depression.

Bowlby (1977) suggests that many psychiatric

disorders stem from deviant attachment patterns to

parental figures which are perpetuated in attempts to

maintain the same distance from other significant figures.

Dependent behavior often serves an adaptive function, as

it binds one in a relationship by increasing the other's

feelings of competence and influence, thus protecting









another from feeling vulnerable. Lerner (1983) cautions

that the dependent individual's reluctance to become more

self-directing in relationships is in part governed by the

press from the dominant partner to retain the illusion of

strength. The systemic destabilization that would result

from the individual's increased autonomy poses a realistic

threat to the security of the relationship. The

individual must go through a process of growth in order to

be willing to take such a risk. Transactional theory

(Symor, 1977) suggests that dependent individuals move

from a position of self-devaluation and other idealization

through a period of angry counterdependence and self-

aggrandizement before they can establish a sense of self

and truly relate in an interdependent fashion that allows

them closeness without compromising their identity.

Therapist Response to Dependent Client Affect

The literature contains theoretical writing and

empirical findings concerning the therapist's mode of

response to dependent clients. Dependency has been

defined by Guerney (1956) in terms of the extent to which

the client turns to others for advice, information, and

evaluations, the amount of structure and guidance required

by the client, and the lack of personal responsibility

taken for the direction and outcome of therapy. The

passive dependent client attempts to gain the therapist's

approval and affection by gratifying the therapist's









narcissistic and omnipotent needs. It is easy for the

therapist to respond in a complementary manner and become

directive and authoritative in behavior. However, the

therapist's assumption of responsibility for client change

and adoption of a dominant position solidifies the

client's feelings of helplessness and characteristic

submissive stance and only provides a new external object

on which to rely (Lerner, 1983; Millon, 1981). A

directive approach can reinforce rather than resolve

dependency needs. Rottschafer and Renzaglia (1962)

reported that assumption of a directive and leading style,

as opposed to a reflective therapeutic approach, appeared

to reinforce dependency expression by clients.

The clinging behavior of dependent personalities is

often aversive to the therapist because of the depth of

client neediness (Groves, 1978). The therapist is likely

to react nontherapeutically by distancing himself from the

client in a self-protective maneuver to prevent

overwhelming feelings of emotional drainage and loss.

Million (1981) encourages the therapist to adopt a close

empathic and nondirective stance to increase the client's

feelings of competency and individuality. While it seems

to be more therapeutically effective to respond with

empathy to client dependency, in practice the therapist's

response to client dependency is often directive and

reassuring (Heller, Myers, & Kline, 1963). Concentrating









on therapists in training (N=18), Bohn (1967) found that

therapists were directive and reassuring when confronted

with clients' dependency expressions, while tending to

avoid clients' expressions of hostility.

Winder, Ahmad, Bandura, and Rau (1962) found

management of dependency in the first two sessions of

therapy to be a critical factor in the client's decision

to commit to or prematurely terminate therapy. Using a

sample of 23 patients and 17 therapists, these investi-

gators found that when the therapist approached and

encouraged the client's expression of dependency, the

client not only continued to explore the issue, but also

tended to remain in therapy. Caracena (1965) was unable

to replicate this finding, reporting no significant effect

of response to client dependency on continuation or

premature termination of therapy. However, the author

suggests that this discrepancy may be due to the higher

levels of dependency approach in Caracena's sample and the

consequent restricted range of behavior on which to test

the hypothesis of long term therapy effects of approach to

client dependency.

The dependent personality sees the therapist as a

benevolent protector, envisioning the therapist as a

strong but kindly rescuer (Millon, 1981). Theoretically,

it is assumed that in order for the client to be able to

explore anxiety provoking material, the therapist must









satisfy his dependency needs. Dollard and Miller (1950)

contend that the client's desire to obtain the therapist's

approval is what initially motivates him to approach

therapy and endure the anxieties that a process of self-

examination entails. Heller & Goldstein (1961) report

empirical findings that support the hypothesis that

initial dependency and beneficial expectations of therapy

are positively correlated. Many analytic writers claim

that the client cannot truly become independent and

capable of relying on the self for direction without a

period of dependency and the resolution of the related

conflicts in therapy. As the client resolves the

conflictual material, his reliance on the therapist's

strength will decrease. This has been empirically

demonstrated by Caracena (1965) and Schuldt (1966).

Caracena's (1965) study revealed that the therapist's

approach or avoidance response to express dependency

behavior was routinely followed by reciprocal behavior

from the client, continuation of expression, or topic

transition, respectively. However, the therapist's

approach to dependency did not appear to act as a

reinforcer, as the number of client initiated dependency

statements was not related to the therapist's behavior.

Schuldt (1966) was able to replicate these findings. He

found that when therapists addressed their clients'

dependency needs as they appeared in therapy the clients









continued to examine these needs; however, while the

therapists were consistent in their tendency to approach

client dependency expressions, the frequency of their

initiation by the client decreased over the course of

therapy. The therapists in this study were consistently

facilitative in response to client dependency needs.

Therapist response to client dependency has been

examined in two studies in terms of whether the dependency

expressions were directed specifically at the therapist or

more generally to others. The results of those studies

have been contradictory. Snyder (1963) found therapists

responded with a much higher rate of reassurance to

therapist-directed as opposed to other-directed

dependency. Reassurance is not necessarily a therapeutic

response, as it often springs from the therapist's need to

quell his anxiety and often directs the client away from

an examination and understanding of his conflicts.

Schuldt (1966) found that therapists were particularly

responsive in approaching client dependency needs directed

at them as opposed to other-directed dependency. It is

unclear from these two studies if therapists respond in

differential manners to direct expressions of

transferential dependency or more generalized statements

involving other parties.









Facilitative Therapeutic Stance

Empathy as the Common Variable

The premise that there exists an ideal therapeutic

relationship whose attributes are endorsed by the

practicing experts from differing psychotherapeutic

schools of thought and supersedes the espoused differences

in theoretical orientation was first researched by Fiedler

(1950). He investigated the idea that discrepancies in

theoretical ideation were semantic in nature, proposing

that experienced therapists from divergent schools would

endorse a common set of beliefs concerning the components

of the maximally effective therapeutic relationship.

Although his sample of 15 psychotherapists is small,

results of the Q-sort technique revealed high and

significant correlations among items described as most

characteristic of a maximally effective therapeutic

relationship among experienced therapists identifying

themselves as psychoanalysts, Adlerian therapists,

nondirective therapists, and eclectic therapists. The

experts agreed with each other to a greater degree than

they did with novices of their own respective schools.

The ideal therapeutic relationship was characterized as an

empathic one wherein the therapist understands and accepts

the patient's feelings and communicates this to the

patient and treats the patient as an equal.

Interestingly, therapists who had undergone personal









therapy and experienced the role of client strongly agreed

with the preeminent importance of these relationship

change characteristics. It has also been shown (Peebles,

1980) that personal therapy experience of counselors is

positively related to their ability to display empathy in

clinical work.

An often quoted contradictory study (Sundland &

Barker, 1962) surveyed 139 practicing psychotherapists

from Sullivanian, Freudian, Rogerian traditions and found

that differences in conceptualization of and reported

activity in psychotherapy were accounted for by

theoretical orientation as opposed to experience level.

While at first these results appear to be incompatible

with Fiedler's (1950) study, the discrepancy in findings

may be attributable to the difference in dimensions of

items available for endorsement between the two studies.

Sundland and Barker (1962) removed all items from the

questionnaire that "were largely expressing that empathy

was important and that the therapist could empathically

relate to his patients [as they] did not

discriminate among therapists in the pilot study"

(p. 210). They removed what was the common variance

amongst therapists' beliefs, and in their discussion

suggested that the uniformly agreed upon empathy variable

may be a component of effectiveness in therapy that is

independent of theoretical orientation. Wogan and









Norcross (1985) obtained similar results in their

investigation of 319 practicing psychotherapists

identifying themselves as behavioral, psychodynamic, and

eclectic therapists. Despite theoretical difference in

professed technique among the three groups, the reliance

on therapist communicated empathy, warmth, and genuineness

as therapeutic interventions was common to therapists from

these dissimilar orientations. Raskin's (1974) study

showed empathy to be consistently ranked first among 12

variables used to describe the ideal therapist by 83

practicing therapists representing 8 different therapeutic

schools of thought.

Reports indicate that level of therapist experience

is a contributing variable in the therapist's ability to

respond empathically to clients. Mullen and Abeles (1971)

rated client sessions across the stages of therapy from 36

different therapists and found that experienced therapists

were more consistent in responding empathically to clients

than the relatively inexperienced group of interns and

practicum students studied. They found experienced

therapists were more aware of the variety and

contradiction in feeling experienced by clients, while

neophyte therapists tended not to differentiate

communicating warmth and nurturance with maintaining an

empathic stance.









There is evidence that experienced, effective

therapists of different orientations are similar in active

therapy behavior, offering high levels of the triad of

core conditions outlined by Rogers (1957) namely, uncondi-

tional positive regard, empathy, and genuineness. Sloane,

Staples, Cristol, Yorkston, and Whipple (1975) reported

that a review of therapy tapes from well-known,

experienced behavioral and psychodynamically oriented

therapists demonstrated high levels of accurate empathy,

genuineness, and unconditional positive regard. Rogers

(1975) states that the provision of empathy by the

therapist is the key to the process of change as it is

positively related to the amount of self-exploration

engaged in by the client. He cites both Barrett-Lennard

(1962) and personal communication of R. Tausch showing

that the amount of empathy communicated within the second

to fifth session is positively correlated with future

success or failure in therapy. Berger (1984) states that

the curative function of empathy can be understood either

as a'means to allowing exploration and insight or as

provision of an experience of shared emotional catharsis

and acceptance that had been lacking in the person's

earlier life.

The literature concerning the relationship between

empathy and therapy outcome is not as clear as the

previously discussed value placed on empathy by practicing









psychotherapists. Parloff (1961) found that outcome

measures of decreased discomfort, increased feelings of

competence and self-understanding, and premature

termination of group psychotherapy patients were related

to the empathic quality of the therapeutic relationship.

Reviewing 166 outcome studies prior to 1969 led Luborsky,

Chandler, Auerbach, Cohen, and Bachrach (1971) to conclude

that there was a consistent relationship between empathy

and outcome. Patterson (1984) highlights that this

positive relationship has been shown across a diverse

client population with highly varied problems. When

utilizing observer ratings of therapist warmth (33

studies) and unconditional positive regard (25 studies),

two-thirds of the studies showed a positive correlation

with outcome, while the remaining third were equivocal

(Orlinsky & Howard, 1978). The review by Truax and

Mitchell (1971) also suggested that the core conditions

were associated with positive therapeutic outcome.

However, Lambert, DeJulio, and Stein (1978) highlight that

reanalysis of these data shows that the relationship

between the facilitative conditions and outcome is not as

consistently predictable as once thought. They do

suggest, however, that a moderate relationship does appear

to exist between these two sets of variables and attribute

some of the discrepancy to methodological problems, such









as inadequate sampling of therapy behaviors and utiliza-

tion of observer ratings of empathy as opposed to client

perceptions of empathy. They report low correlations

among empathy ratings from various perceptions--judge,

therapist, client, and trait measures. To date the

client's perception of feeling understood has appeared to

be most consistently associated with outcome (Free, Green,

Grace, Chernus, & Whitman, 1985; Gurman, 1977). This

finding supports Rogers' (1975) theoretical contention

that clients are the best judges of their therapist's

degree of empathy.

The other two reviews (Mitchell, Bozarth, & Krauft,

1977; Parloff, Waskow, & Wolfe, 1978) which argue against

the primary relationship of empathy to therapeutic outcome

are not convincing, as they rely on studies having a very

low and restricted range of empathic therapists. They

discount the preponderance of evidence of a positive

relationship between empathy and outcome, while empha-

sizing the flawed studies that did not find such a

relationship. Their basic argument is that empathy cannot

be considered a necessary and sufficient condition of

therapy, as its presence does not always result in client

change. This appears to be an unfair expectation, given

both clinicians' imperfect empathic abilities and the

limitations of our research methodology to assess

subtleties in client change over an extended period of









time. Furthermore, as Patterson (1984) argues in his

review of this controversy over the efficacy of empathy,

despite the biases of reviewers and the multiple

references to the supremacy of therapeutic technique,

". there is no good evidence for the effectiveness of

other approaches in the absence of these conditions

[empathy, warmth, and congruence]" (p. 435).

Another reason for the confusing findings concerning

the relationship between empathy and therapy outcome has

to do with the multidimensional nature of the concept of

empathy and which aspects are being measured (Davis, 1983;

Deutsch & Modle, 1975). Two types of empathy have been

differentiated in the literature--cognitive empathy and

affective empathy. Cognitive empathy refers to the

ability to intellectually perceive the position of another

and accurately predict another's feelings and thoughts.

This type of empathy is often referred to as role-taking

empathy. Affective empathy refers to the tendency to

resonate with another's feelings, to allow yourself to

vicariously experience the emotion that another is

communicating. It is thought (Gladstein, 1983) that

affective empathy develops prior to cognitive empathy, but

apart from the developmental sequence these two components

of empathy are believed to be tapping separate

characteristics (Deutsch and Modle, 1975). Recent

research (Davis, 1983) suggests that indeed these may be









two separate attributes, as measurements of each have

different and theoretically predictable patterns of

correlation with emotional and cognitive subscales on the

Interpersonal Reactivity Index, a multidimensionally

constructed empathy measure (Davis, 1983).

A three-stage empathy cycle has been proposed

(Barrett-Lennard, 1981). The emotional resonation occurs

first with the counselor losing the distinction between

self and other and temporarily merges with the client.

This merger is then transformed into a conscious and

distancing cognitive inferential process wherein the "as

if" quality is restored while moral judgments remain

suspended. The third is the communication of the

experience and understanding of the other's reality

(Berger, 1984; Gladstein & Feldstein, 1983). Different

abilities are required for each of the three stages. An

analogue therapy study conducted by Corcoran (1983) showed

a significant negative correlation between empathic

resonation and emotional separation, while the communi-

cation of this empathy was unrelated to maintenance of

self-other differentiation. It is clear that those high

in affective empathy can recognize the feelings of others,

but it is not clear if this ability translates into

empathic communication of those feelings. While the

feeling may be experienced, the vocabulary to identify it









or the courage to express it may be absent (Kagan &

Schneider, 1987).

It has also been suggested that affective empathy may

actually hinder the therapeutic process during the problem

identification stage, as it has been hypothesized that

counselors high in affective empathy may easily become

overwhelmed with their client's emotion and have to

psychologically withdraw from the client in a self-

protective fashion (Gladstein, 1983). Peabody and Gelso

(1982) conducted a counseling analogue study and found

that therapists who were aware of their own emotional

resonation and countertransferential feelings also tended

to withdraw from seductive clients when their reactions

were too strong. They found that while they were able to

pick accurate empathic response, they consistently chose

responses that were a generalized statement of the

client's emotional state and did not involve themselves or

the therapeutic relationship personally in reflecting the

source of the affect.

It is suggested that the therapist's level of

cognitive empathy may be a key variable in his ability to

stay with and explore the negative affect presented by his

client. This relationship appears to be conceptually

based on the positive correlation found between the

therapist's emotional stability and his level of cognitive

empathy. Persons high in cognitive empathy are described









as well-adjusted, warm, flexible, optimistic, emotionally

mature, and tactful (Dymond, 1950; Hogan, 1969). They

have been found to be more effective communicators because

they tailor their responses to the needs of the audience

(Hogan & Henley, 1970). Empathy has also been positively

correlated with ego development, as measured by

Loevinger's Sentence Completion Test (Carlozzi, Gaa, &

Liberman, 1983). This is a logical connection as

cognitive empathy requires the maintenance of self-other

differentiation, which in turn rests upon a securely

developed sense of self (Deutsch & Modle, 1975). Persons

who are high in role-taking empathy tend to be accurate in

their self-perception (Mills & Hogan, 1978) as well as

their perceptions of others (Borman, 1979). Comparisons

of empathy scores with other personality measures such as

the Thematic Apperception Test (TAT), Rorschach, and the

California Authoritarianism Scale, show positive

correlations between empathy and other attributes of a

well-adjusted personality such as warmth, security,

interest in relating to others, and awareness of and

control of emotions (Dymond, 1950). Studies have also

shown a corresponding negative correlation between empathy

and maladjustment, as measured by the clinical scales of

the Minnesota Multiphasic Personality Inventory (Hogan,

1969) and specifically with trait anxiety, as measured by









the State-Trait Anxiety Inventory (Deardoff, Kendall,

Finch, & Sitarz, 1977).

Countertransference

It has been stated that the therapist's personality

is his most important tool (Reik, 1948). However, this

tool is an imperfect one and at times the inherent flaws

contribute to difficulties in maintaining a facilitative

posture with clients in the form of countertransference.

Freud (1910/1957) was the first to mention counter-

transference. He defined it as the therapist's neurotic

transference reaction to the client's transference.

Countertransference was seen as an impediment to treatment

and these infantile ideas were obstacles to be overcome.

"We have noticed that no psycho-analyst goes further than

his own complexes and internal resistances permit" (Freud

1910/1957, p. 145).

Over the years two schools of thought developed

concerning the origin and utilization of this phenomena

(Baum, 1970). The classical analysts uphold Freud's

original thinking on the concept, believing it is an

unconscious process whereby unresolved issues are

triggered by the patient's playing out unconscious

material; this is to be handled by further personal

therapy for the practitioner (Fliess, 1953; Gitelson,

1952; Reich, 1951, 1960). They focus only on the

unconscious processes effecting the therapeutic









relationship and exclude reality-based, more objective,

reactions to the patient's behavior. This group stresses

that the stability of idiosyncratic personality

characteristics suggests that the therapist's unconscious

needs and conflicts remain relatively unchanged without

direct address. Consequently, the situations that evoke

countertransferential reactions within a particular

therapist are set, and the specific responses are

predetermined by the therapist's neurotic resolution of

his own difficulties in this area (Reich, 1951). Often

the therapist is not cognizant of the specific infantile

associations being triggered; the presence of counter-

transference is experienced as feelings of anxiety, an

increased intensity of affect, blockages in understanding

the patient, and boredom within the session (Reich, 1960).

Cutler (1958) investigated therapists' responses to

patients' presentations of material that had been

designated as personally conflictual for the therapist.

He found that therapists were unable to maintain their

therapeutic objectivity in relation to the personally

conflictual material. They continually distorted the

relative importance of these issues in the treatment cases

and responded defensively when the clients raised these

issues.

The alternative school of thought is represented by

the following clinicians: Fromm-Reichmann (1949, 1950),









Heimann (1950), Joseph (1985), Kernberg (1965), Little

(1951), Money-Kyrle (1956), Racker (1957), Sullivan

(1949), and Winnicott (1949). They have expanded the

concept of countertransference to include conscious as

well as unconscious feelings toward and attitudes about a

specific client and suggest that the arousing of such

emotions is the patient's doing. This group also views

countertransference more positively, focusing upon the

insight afforded into the client's thoughts and emotional

concerns via reflection upon the therapist's affect and

fantasies in connection with the sessions. That the

therapist's own emotional reactions to a patient can be

used reliably to understand the patient's own impulses and

defensive maneuvering, is predicated on the existence of

projective identification which links the corresponding

unconscious processes of therapist and patient (Racker,

1957). Projective identification proposes that that which

is unacceptable in the self and previously experienced as

unsatisfactory interactional patterns, are called forth in

others in order to try and work through the inner turmoil

in an external situation.

While those taking the classical position suggest

that the therapist's own specific infantile strivings

contaminate the transferential field, Kernberg (1965)

asserts that the countertransference of reasonably healthy

therapists dealing with the same severely disturbed









patient will be similar and a reflection of the patient's

state and not the counselor's problems. He states that

the countertransference is an important diagnostic tool in

assessing the amount of regression and prevailing

affective position of the patient, as in effect, the

therapist is mimicking the patient's process (Kernberg,

1965). As Heimann (1950) explains, "the analyst's

countertransference is an instrument of research into the

patient's unconscious" (p. 81). Through the counter-

transference the therapist gains clues as to how the

patient was treated by the primary objects in his life,

and thus can effect a corrective emotional experience by

responding in a manner different from those objects

(Zetzel, 1956).

Howard, Orlinsky, and Hill (1969) investigated the

congruence of patient and therapist emotions during

sessions. Using all female patients and experienced

therapists, they gathered self-report data independently

on the subjective emotional experience of therapist-

patient pairs during multiple sessions once the

therapeutic relationship had been established. While

acknowledging the limitation that excluding male patients

had on the generalizability of the findings, the results

of this preliminary investigation were interesting. Both

the patient's emotional experience and the therapist's

gender appeared to impact upon the feeling state of the









counselor. Female therapists were responsive to the

patient's experience of positive transference and intense

feelings of dependence. They reported feeling calm when

the level of positive transference reported was high, and

feeling preoccupied and resigned when it was low. The

female practitioners tended to withdraw and not feel

nurturing or warm in conjunction with the strong

dependency needs of these patients. Concurrence of

emotional state was demonstrated with male therapists

feeling disturbed by sexual arousal in sessions when the

female patients were likewise reporting embarrassing

erotic transference. Similarity of subjective experience

was found with therapists on the whole feeling withdrawn

and a sense of failure when the patients reported low

levels of collaborative involvement in therapy. The

authors concluded that their investigation supported the

contention that the practitioner's feeling in session

provided clues to the patient's concurrent emotional

state.

Those with a more inclusive view of counter-

transference stress that the professional needs to attend

closely to his emotional responses and decry the phobic

attitude the classical analytical writers have endorsed

regarding its appearance. They state that this phobic

attitude results in unfeeling, detached, impersonal

therapists who repress much of the relevant information









received that could guide appropriate interventions

(Heimann, 1950; Joseph, 1985; Kernberg, 1965; Little,

1951).

Countertransference is often denied by the

professional fearing that the acknowledgment of such

feelings would ruin his empathic stance toward the patient

(Epstein, 1977). However, both empathy and counter-

transference are thought to result from partial

identification with the patient, as the unconscious

of both contain the same desires. The difference in

these two concepts is that the former has a more

transient nature, while the latter is a regressive and

longer-lasting identification that gets the therapist

reembroiled in his own unresolved conflicts (Fliess, 1953;

Money-Kyrle, 1956; Reich, 1960; Reik, 1948). Empathy

involves the use of only a small amount of energy to

identify the fleeting feeling of another, yet the degree

of concentration in countertransference is all-absorbing

and the boundary between client and therapist affect is

blurred (Baum, 1970).

Peabody and Gelso (1982) studied empathy and

countertransference, defined as withdrawal from the

patient, in counselor trainees and found a tendency for

the more empathic counselors to be more aware of their own

internal emotional fluctuations, while being less likely

to exhibit countertransferential behavior. The authors









suggested that empathy mediated the self-protective

tendency to become emotionally detached in psychologically

threatening situations. This relationship held up as long

as counselors were not overly preoccupied with their

internal reactions. These findings lend credence to

the theoretical belief that while extensive and

differentiating emotional sensitivity is required of a

therapist, it is the intensity and duration of

countertransference feelings that interfere with the

counselor's ability to be effective, as they preclude

effortless attention to the patient's needs and

fluctuating emotions (Baum, 1970; Heimann, 1950;

Winnicott, 1949).

Winnicott (1949) speaks about objective

countertransference, the therapist's reality based

reactions to the actual personality and behavior of the

client. Negative reactions are inevitable when working

with severe character disorders and psychotics. Examples

of common reactions to client types include the following:

feelings of aversion that are often elicited by profoundly

dependent persons, the desire to attack which often

appears in response to work with demanding and entitled

clients, and depressive affect resulting from work with

manipulative help-rejectors (Poggi & Ganzarian, 1983). As

Little (1951) states, the more disintegrated the patient

the more integrated the therapist needs to be, so that the









therapist can allow his ideas to regress associatively,

and then to process them on a rational level to help the

patient integrate them. The more the practitioner is

cognizant of both his love for and his hate and fear of

the patient, the less these will unwittingly influence his

interaction with the patient (Winnicott, 1949).

It is emphasized that the therapist needs to sustain

his feelings in order to cognitively understand what they

are revealing about the patient (Heimann, 1950). While

being aware of the countertransference, therapeutic

progress is inhibited by acting upon these internal

reactions and discharging them indiscriminately (Heimann,

1950; Racker, 1957; Winnicott, 1949). The strong

reactions must be diluted to a tolerable dosage for the

patient to absorb without increasing anxiety and

retaliation. Through the therapist's modeling exposure of

these titrated doses of his own irrationality, the patient

can learn not to fear and avoid such impulses in the self,

while sensing insincerity as the counselor attempts to

mask his responses, will most likely elicit the patient's

hostility as he is once again abandoned in the reality

testing function he needs (Little, 1951).

The therapist is particularly vulnerable to defensive

reactions to a patient's hostile attack (Glover, 1955) and

feelings of hate must be reduced to irritation before they

can be effectively communicated (Epstein, 1977).









Counselors wish to be helpful, but often the reparative

efforts fail through incomplete understanding of a patient

whose conflicts are too similar to the therapist's issues.

Such a situation promotes anxiety in the therapist, who

will often then withdraw from the patient and offer

reassurance instead of treatment. This ineffectiveness

also often evokes depressive feelings and defensive anger,

which serves to increase the client's hostile attacks and

exacerbate a nonproductive relationship (Money-Kyrle,

1956).

Therapist Personality Characteristics Associated with
Countertransferential Reactions to Hostile Clients

While in general therapists have difficulty in

maintaining a therapeutic posture with respect to an

overtly hostile client, not all counselors demonstrate the

same degree of difficulty. The individual differences in

appropriateness of response may be a function of their own

personality characteristics. In addition to empathy, the

following therapist personality traits have been suggested

as possible links to countertransferential interference in

the therapy of hostile clients: anxiety, need for

approval, and hostility (Keren-Zvi, 1980).

The linkage of these four variables to counter-

transferential responses to hostility is theoretically

grounded. Fromm-Reichmann (1950) suggests that the

therapist's level of personal security is positively

correlated with his ability to respond facilitatively to









his client's hostile reactions. Doing effective work with

clients always elicits their hostility because it involves

uncovering and dismantling their defenses, which heightens

their experience of anxiety and prompts attacks on the

force responsible for this distress. The practitioner can

correctly perceive the defensive nature of the client's

hostility only if he can maintain his own feelings of

personal safety and security. When therapists are faced

with issues that are personally threatening, they tend to

deter the client from further exploration of that area

(Cormier & Hackney, 1979). Both self-report (Parsons &

Parker, 1968) and physiological measures, along with

reports of trained observers (Russell & Snyder, 1963),

show therapists become more anxious in response to hostile

clients than to dependent or friendly clients. Parsons

and Parker (1968) suggest that this is a basic social

response that may not be amenable to general counselor

training.

When the therapist is made anxious by the client's

behavior, he cannot be sensitive to his own internal

responses to the client as clues to the client's state

because his response has been masked with anxiety. When

anxious, the therapist is more directed toward

reestablishing and preserving his own identity, and less

energy is available to objectively observe and understand

the client's perspective (Kohut, 1971; Meares, 1983). In









fact, Cohen (1952) defines countertransference as a

disruption in therapeutic communication because of the

arousal of anxiety in the therapist.

The tendency of therapists to become anxious in the

presence of hostile clients complicates the therapeutic

process. Anxiety interferes with the performance of

complex tasks (Spence, Taylor, & Ketchel, 1956). An

anxious therapist is also seen as less competent (Bandura,

1956), and the client's perception of the counselor's

competency has been shown to be related to therapeutic

outcome (Orlinsky & Howard, 1978). Typically the

counselor diffuses the induced feelings of anxiety by

psychologically moving away from the patient. Awareness

of their own anxiety did not impact on the therapists'

tendency to offer reassurance, ask tangential questions,

offer premature and harsh interpretations, or hint at

disapproval. These responses were all designed to elicit

a transition to a less conflictual topic for the therapist

(Bandura, 1956).

Yulis and Kiesler (1968) investigated the effect of

therapist anxiety on the response tendency toward hostile,

seductive, and neutral clients. The authors found that

therapists high in anxiety tended to make content related

interpretations as opposed to transference interpreta-

tions, irrespective of client type. Counselors high

in trait anxiety attempted to focus away from the









client-therapist relationship, and their responses were

geared to maintaining distance, being on the whole

defensively oriented. This study suggested that anxiety

is not the only therapist characteristic that influences

responses to hostile clients, as the highly anxious

therapist group showed a wider latitude in response to

hostile as opposed to neutral clients.

Clinical experience has led to the conclusion that

the therapist's fear of his own anger (Adler, 1972) and

guilt about personal feelings of hostility (Maltsberger &

Buie, 1974) tend to make him inhibit and misperceive the

hostile expressions of his clients. It has also been

suggested by Greenson (1974) that therapists who tend to

respond to hostility with sarcasm and counteraggression in

their everyday life will have difficulty in abandoning

this style and being facilitative when confronted with

hostility in their clinical work.

Treatment with a hostile client means that the

therapist must endure periods of devaluation by his

client. This ability rests upon the counselor's having a

reasonably stable self-esteem. When therapists rely upon

a client's admiration to boost their prestige, their

spontaneity is interfered, with and insidiously their

interventions become motivated by the need to keep the

client dependent upon them, thus maintaining their own

supply of narcissistic need fulfillment (Fromm-Reichmann,









1949). The therapist's need for approval is conceptually

related to his ability to respond to client hostility, as

those who can rely on internal self-evaluations will not

be prompted to seek assurance from their patients as to

their competency and, consequently, they will not be

threatened by their clients' disparagements. If the

therapist has a need to be liked by his patients he will

work toward maintaining harmony in the therapeutic

situation and will attempt to avoid recognition of his

client's hostile affect, and thereby seriously compromise

his therapeutic effectiveness (Maltsberger & Buie, 1974).

Hostile attacks by clients can be damaging to both

professional and personal self-esteem if these are

determined by transitory and external sources of

affirmation. Hostile patients present difficult

management situations and a possible failure experience,

and thus may pose a threat to the therapist who requires

professional admiration of his skill to maintain his self-

esteem (Keren-Zvi, 1980).

The studies conducted to date on the impact of the

therapist's own personality on his handling of a hostile

client have been exploratory in nature. The first study

probing this issue was Bandura, Lipsher, and Miller's

(1960) investigation. These researchers found that

therapists who directly expressed their feelings of

hostility in their everyday behavior were significantly









more likely to approach hostility directed at others;

however, this factor did not influence their ability to

facilitatively respond to hostility directed at them.

This latter ability was found to be uniformly low across

therapists. The therapists' need for approval, as

measured by sociometric ratings, was inversely related to

their tendency to approach the clients' hostility,

irrespective of the direction of the hostility.

Similarly, Henry (1981) found that beginning counselors

who were willing to place themselves in an unfavorable

light by admitting socially unacceptable feelings and

behaviors, and were low in hostility expression, responded

more appropriately to therapist-directed hostility than

their counterparts.

Keren-Zvi (1980) investigated the impact of the

therapist variables of anxiety, hostility, need for

approval, and level of experience on the therapist's

tendency to respond with empathy, avoidance, or

counterhostility to hostile clients. These categories of

response tendencies are garnered from Karen Homey's

(1945) theory of interpersonal styles and represent moving

toward, moving away, and moving against character styles,

respectively. His sample consisted of 100 psychody-

namically oriented therapists, with equal numbers of male

and female subjects. The therapists responded via a

multiple choice format to four audiotapes wherein client









sex and affect, hostile or nonhostile, were crossed. On

the whole, therapists tended to respond with more

counterhostility to hostile patients, while being more

avoidant with nonhostile patients when the two client

types were compared. The results were analyzed separately

for male and female therapists, as there were significant

sex differences. The female subjects endorsed more

facilitative responses than the male subjects. They also

reported a higher level of trait anxiety and had less

experience than the male therapists. This study found

that the level of global experience was not a

significantly influential variable on therapist response

tendency.

It had been hypothesized that the therapists would

respond more facilitatively to nonhostile, as opposed to

hostile, clients. This hypothesis was not supported by

data generated from either the male or female sample.

Both samples responded with essentially equal numbers of

facilitative responses to both clients types.

The therapist personality variables under investiga-

gation were significantly correlated with response choices

for female, but not male subjects. Females high in trait

anxiety, as measured by the State-Trait Anxiety Inventory

(STAI), and hostility, as measured by the Buss-Durkee

Hostility Inventory (BDHI), responded significantly less

facilitatively to hostile patients than subjects scoring









low on these attributes. Further analysis showed that

high anxious female subjects tended to avoid hostile

patients more and counteraggress against them less.

While these results were in the predicted direction,

the relationship between the female subjects' need for

approval, as measured by the Marlowe-Crowne Social

Desirability Scale (M-CSDS), and their responses to

hostile patients was opposite to the hypothesized

relationship. Female therapists high in need for approval

were more facilitative with hostile patients. The author

interpreted these findings as suggesting that, while the

therapists' high anxiety and hostility levels inhibited

facilitative responses to hostility and resulted in

avoidant tendencies, a high need for approval may motivate

therapists to endure the discomfort associated with

approaching client hostility.

The author performed multiple regression analyses on

the personality variables for each of the three criterion

response categories. The following results were reported

for the female subjects: need for approval and anxiety

together accounted for 10% of the variance of the moving

toward facilitativee) response; anxiety accounted for 11%

of the variance of the moving against (counterhostile)

response; and anxiety accounted for 17% of the variance of

moving away (avoidant) response.









The results of this study suggest that further

investigation into the impact of personality variables on

response style with the hostile client is warranted. The

therapist's level of anxiety appears to be the variable

most clearly related to response style. Examination of

the response choices offered suggest that it may have been

the blatant nature of the responses which influenced their

endorsement frequency and, consequently, masked the impact

of the personality variables. The author suggested that

an open-ended response format might more accurately

reflect the impact of the personality variables on the

therapist's responses. This suggestion was followed by

the present author in an unpublished pilot study, but this

format was found to have its own drawbacks (i.e., low

interrater reliability in coding of subject generated

responses) and the results were disappointing (Appen-

dix A). Keren-Zvi (1980) also suggested that his results

may also have been due to the absence of a key personality

variable and hypothesized that the empathy level of the

therapist may be an influential variable that accounts for

endorsement of response style.

Therapist Experience Level

The experience level of the therapist is a variable

that has been looked at in relation to the impact the

client's affect has on both the therapist's emotional

state and his ability to respond facilitatively. However,









the majority of studies (Bohn, 1965, 1967; Donner &

Schonfield, 1975; Henry, 1981; Murphy & Lamb, 1973;

Russell & Snyder, 1963) concern novice therapists in

graduate school and the varying experience levels are

often determined by the current practicum semester. The

possible range of level of expertise is thus often

limited. It has been shown that novice counselors are

more apt to be personally affected by their client's anger

than by other emotions expressed by clients. Donner and

Schonfield's (1975) in vivo study investigated the amount

of emotional contagion experienced by the therapist in

relation to three patient groups, those expressing

anxiety, depression, and hostility. Their results showed

that following a session the more conflicted therapists,

as measured by an actual-ideal self-discrepancy, reported

an increase in the affect displayed by their patient.

While over the period of four sessions there is less

emotional contagion shown by the more conflicted

therapists in relation to anxious and depressed patients,

there is no such decrease in connection with the

experience of hostile affect following an interaction with

an angry client. Furthermore, over the four sessions even

the more stable therapists began to report feeling

personally angry after their sessions with the

antagonistic client. Therapists in this study appeared to

be personally affected by their client's hostility.









Henry's (1981) study also showed that hostile client

behavior increases the anxiety level of the therapist.

She found that the responses of inexperienced counselors

could be characterized as defensive, disapproving, and

often inaccurate in perception of the situation when

dealing with hostile clients. Unfortunately, experience

does not appear to lessen the therapist's anxious reaction

to client animosity. An analogue study by Russell and

Snyder (1963) demonstrated that the anxiety level of the

therapist remains high when working with a hostile patient

and does not dissipate with further training and

experience. Unfortunately, they do not delineate their

experience groupings beyond the labels of "more" and

"less" experience categories. Similarly, Murphy and Lamb

(1973) found that psychotherapy training resulted in only

a minimal decrease in therapist anxiety when confronted

with a hostile client. They compared master's level

clinical students with school counselors having no

psychotherapeutic training and found that while the

therapists tended to give fewer direct suggestions than

the control group after training, they also tended to

interpret more and increased the amount of silence, and

neither of these behaviors shows an increase in empathic

communication with the hostile client. However, findings

from this study should be cautiously interpreted because

of the small sample size (N=6) and the relatively short









training period (14 weeks). Training specifically focused

upon consistent responding to hostile affect may be

beneficial. Hector et al. (1981) found a combination of

verbal and modeling strategies to be effective in training

beginning counselors to respond facilitatively to both

angry and depressed clients.

It is not clear if more experienced therapists

respond more facilitatively to client dependency

expressions than novice therapists do. Caracena (1965)

reported that staff therapists approached dependency more

than trainees, while Bohn (1967) found that a semester of

training did not significantly decrease the therapists'

tendency to be directive in response to client dependency.

The variation in range of experience levels in the two

studies may account for the conflicting findings. One

semester of training may not be enough to affect the

therapists' style of handling dependency. However, Bohn

(1967) did find that these same therapists were less

directive in response to client hostility after the

semester's training. He concluded that experience does

not necessarily effect response tendencies to these two

affects in the same manner. These contradictory findings

may also be explained by a different amount of experience

with dependent clients between the two samples.

Strupp (1980b) retrospectively analyzed the process

of therapy of dependent individuals treated by the same








experienced therapist, one resulting in a successful

outcome, while the other was considered a failure. Strupp

surmised that the inability to develop a therapeutic

alliance in the unsuccessful treatment stemmed from the

therapist's adaption of a directive stance and the

repeated imposition of interpretations in response to the

client's open resistance and negativistic attitude. He

offered the analysis as evidence for his belief that,

while experience increases effectiveness with motivated

clients, this factor has a negligible impact in the

treatment of hostile and resistant patients.

The literature comparing therapist response to

hostile clients versus depressed clients has touched on

both the layman's approach and the trained professional's

tendencies. Haccoun, Allen, and Fader (1976) found that

untrained college peers responded differentially to angry

and sad clients. Angry clients elicited judgmental

statements concerning the inappropriateness of the

client's behavior, while peer response to depressed

clients was supportive involving listening, encouragement

of emotional expression, and reassurance. A followup

study (Haccoun & Laviguer, 1979) reported that experienced

therapists were less negative in their evaluation of angry

clients than inexperienced therapists, who saw them as

having poor personal controls and as much less able to

benefit from therapy than the sad/depressed client. This









study indicated that, on the whole, therapists were more

detached and less supportive and eliciting of exploration

of emotion with angry, as opposed to sad, clients. It was

most unfortunate that they did not report on the effect of

experience level on these response tendencies, as the

range of expertise was wider than in the previous studies,

extending from groups with less than 6 cases to greater

than 100 prior patients.

Researchers have investigated the interactive effects

of therapist experience level and client attitude focused

upon hostile and friendly clients. Berry's (1970)

analogue study used two groups of therapists, prepracticum

clinical psychology graduate students and professional

therapists with at least four years experience.

Experienced and novice therapists were both more

facilitative with the friendly, as opposed to the hostile,

client. While experienced therapists were more empathic

with both types of clients than novice counselors, they

were unable to maintain their high level of acceptance and

warmth with the hostile client. Client affect undermined

their ability to provide unconditional positive regard

despite their level of training experience. One

methodological drawback in this study concerns the fact

that each therapist saw only one client, and therefore the

individual subject's response to hostile and friendly









clients could not be compared; experience group

comparisons were used instead.

Previous studies have compared therapist responses to

dependent and hostile clients. Bohn (1965) compared the

response styles of inexperienced undergraduates and

graduate counseling students with one semester of

experience with dependent and hostile clients. He

reported that experienced counselors tended to be more

nondirective with both types of clients than inexperienced

subjects. However, he also found that counselors were

more directive with the dependent client, regardless of

their training level or their tendency to be dominant in

relationships. Therefore, it appeared that both client

affect and training effect the therapist's ability to

remain nondirective. In addition, Parsons and Parker

(1968), using an all male subject pool, compared the

responses of psychiatrists, medical students, and

undergraduates to both dependent and hostile clients in an

initial interaction. They found that all groups favored

the dependent client, expressing more acceptance of the *

client and feeling less anxious in the therapeutic

situation. The psychiatrists did differ from the other

samples in their verbal responses to the hostile client;

they were lower in both verbal aggression and attempts to

control the session than the untrained subjects. The

authors noted that there was a trend for directiveness to









decrease with increasing therapeutic experience, while

being unrelated to educational level attained.

Interestingly, they found that while the experience factor

effected the therapists' verbal expressions, it did not

ameliorate the underlying more negative attitude toward

hostile clients, and they hypothesized that this

discrepancy would wear on the therapy and taint the

therapists' communication as they proceeded past the

initial stages of therapy and their more facilitative

responses were extinguished.

The studies reported are faulty and replete with

small samples, unarticulated experience criteria,

restricted ranges of expertise, and incomplete analyses of

the data. However, despite these limitations the finding

that therapists tend to be directive in response to

dependency and are adversely effected by client hostility,

coupled with the uncertainty that these undermining

response tendencies dissipate with experience, resounds

through this review.

Gender Effects

Preference for Therapist Gender

The relationship between the sexual composition of

the therapeutic dyad and both client and therapist

response tendencies has been addressed in the literature.

Client preferences for therapist gender has been

considered. Fuller (1963), Boulware and Holmes (1970),









and Chesler (1971) found, in line with previous

reporting, that both male and female clients preferred

male counselors and that cross gender preference from male

clients was an extremely rare event. Chesler's (1971)

data were impressive, as she surveyed over 1000 clients

and of the 25% who stated a preference, the overwhelming

desire was for a male therapist independent of client sex.

This preference for male therapists has been linked to

differential status generalizations between the sexes

(Fuller, 1964) and women's socially reinforced low self-

esteem level. Fuller's (1963) analyses of actual

counseling sessions revealed that both counselor

experience and receipt of therapy by a counselor of the

preferred gender increased the client's ability to explore

and express affect. This study concerned clients seeking

help for vocational and educational problems. A followup

study was done including personal as well as vocational

issues, and included both nonclient student subjects

hypothesizing their behavior and the recording of actual

client behavior. While again finding that both males and

females preferred male counselors when stating a prefer-

ence, there was a tendency for females to request female

counselors when the hypothesized presenting problem was

personal in nature (Fuller, 1964). This differed from

sampled actual clients' preferences within the same study,

wherein female clients requested male therapists for both









vocational and personal problems. It was striking that

following therapy, clients who had requested female

therapists more frequently changed their stated preference

to male counselors than clients who had initially asked

for and received treatment from a male therapist. Thus,

the tentative suggestion was that same gender requests

were limited to hypothetical situations, whereas actual

therapy seeking behavior was strongly linked with a desire

for a male therapist despite the problem being addressed.

This literature predates the feminist movement. These

findings are not unexpected, given the limited exposure to

women in varying roles that was available at the time.

There has been a change regarding therapist

preference through the years as attitudes toward women

have been altered and as the pertinent research questions

have become more finely tuned. An overview of the more

recent studies (Maracek & Johnson, 1980) suggests that

frequently the client does not have a preference for the

gender of his therapist. When a preference is shown, it

is usually the younger, female clients who have a strong

desire for a female therapist, as the women are perceived

as more empathic, genuinely concerned, and comforting than

male counselors (Davidson, 1976; Simons & Helms, 1976),

while male clients are rather indifferent to the sex of

their counselor (Banikiotes & Merluzzi, 1981; Walker &

Stake, 1978; Yanico & Hardin, 1985). Over the years









female therapists have become more acceptable to both

sexes. As the studies became more refined in terms of

type of stimulus problem, therapist gender preference was

shown to be a function of the specific nature of the

problem for which subjects were consulting a professional.

Males still tend to be chosen for addressing vocational

concerns, while females are desired by both sexes for help

with such problems as rape, childrearing, pregnancy, and

sexual harassment (Lee, Hallberg, Jones, & Haase, 1980;

Yanico & Hardin, 1985). When asked, subjects consistently

stated that they were basing their preference on the

belief that therapists of the chosen gender would be

better able to understand the problems (Boulware & Holmes,

1970; Davidson, 1976; Simons & Helms, 1976; Yanico &

Hardin, 1985).

Gender and Empathy

The hypothesis that females on the whole are more

interpersonally sensitive and responsive and therefore,

more empathic than males, has repeatedly been put forward

in the literature (Freud, 1925/1961; Hogan, 1969; Koffka,

1935; Parsons & Bales, 1955). Sociologists theorize that

ascribed functions within stereotyped role behavior

account for this difference. Specifically, females are

expected to adopt the expressive role within the family,

seeing to its members' emotional needs and maintaining

harmony, while the males are induced to fulfill an









instrumental role, becoming active problem-solvers and

task masters with little emphasis on developing their

capacity for emotional responsiveness (Parsons & Bales,

1955). Thus, this school of thought views this gender

discrepancy as resulting from culturally reinforced role

inductions.

The reasons postulated by the psychoanalytic thinkers

for this "female empathy advantage" are none too

flattering. Freud (1925/1961) felt that women were more

empathic because of incomplete resolution of the Oedipal

complex, which resulted in an "inherently" weaker ego and

superego; being at a more primitive level of psychosexual

development, they were more influenced by the irrational

affective life of the id. Other psychoanalytic writers

(Bakan, 1966; Wyatt, 1967) have similarly suggested that

the theorized relatively lower levels of ego development

in women are reflected in more permeable boundaries around

the self. This diminished sense of differentiation from

others is thought to account for the increased sensitivity

to others and ability to vicariously experience another's

affect.

Hoffman (1977), in his review of the literature on

sex differences in empathy, notes that theoreticians do

not dispute this popular stereotype and concludes that the

empirical findings support this contention throughout the

life cycle. His review covered sixteen independent









samples, all but one consisting of children. While the

amount of difference between the sexes was not always

significant, he did note that in all 16 samples the

females outscored the males. He pointed out that the

difference was significant on each of the six studies on

affective empathy, while the findings were equivocal on

the seven studies concerning cognitive empathy. Hoffman

(1977) concluded that the sex difference in empathy did

not extend to the recognition of affect in others and

suggested that females' ability to vicariously experience

another's affect may be due to their tendency to imagine

themselves in the other's shoes while.retaining the as-if

quality of the experience, and termed this process a

"regression in service of empathy" (p. 718). He refuted

the notion that this capacity reflected a lower level of

achieved individuation, as he found (Hoffman, 1975) that

female children and adults experienced more guilt in

reality situations than men, and thus did not have weaker

consciences.

Results of a meta-analysis reported by Hall (1978) on

75 studies neglected in Hoffman's review contradicted the

above mentioned finding that sex differences did not

extend to cognitive empathy. Hall (1978) found that

females across all ages significantly outscored males in

their ability to recognize another's affect through

nonverbal visual and auditory cues. While Eisenberg and









Lennon (1983), in their review of these studies, did not

find the evidence as compelling as did Hall for the

superiority of female children's visual decoding

abilities, they did uphold Hall's findings concerning the

adult population as well as female superiority in

nonverbal auditory deciphering independent of age. Thus,

the literature does indicate that sex differences in

empathic abilities exist from childhood on and these

differences may encompass both affective and cognitive

empathy.

The inconsistencies in the findings concerning sex

differences and empathy appear related to the varying

methodologies used. Eisenberg and Lennon (1983),

primarily using meta-analyses of relevant research

studies, found no significant differences in empathy

responses of adults when physiological measures were used,

or in children when unobtrusive observations of nonverbal

responses to others' distress were taken. They found a

positive correlation between the demand characteristics in

the experimental situation and the size of the sex

discrepancy in self-reports of empathy. The most

pronounced gender difference for both children and adults

was found when self-report questionnaire scales were

utilized. The authors suggested that the females' higher

endorsement of empathy was syntonic with gender identity,

as it has been stereotyped as a feminine trait.









The few studies located comparing global empathy

differences in psychotherapists across genders yielded

discrepant results among both students and practicing

clinicians. Abramowitz, Abramowitz, and Weitz (1976)

sampled a class of ten male and eight female graduate

student psychotherapy trainees with thirty hours of past

supervision both prior to and following a semester

practicum. The subjects originated their own responses to

videotaped client role plays. The authors found that

while with training both sexes improved in their empathic

responsiveness, female trainees were judged to be more

facilitative than their male counterparts both before and

after training, although the latter did not reach

statistical significance. These results were replicated

on an equivalent sample (Abramowitz, Abramowitz, & Weitz,

1976). However, an analogue study by Breisinger (1976)

showed no gender difference in the level of empathic

responding by graduate counseling students to videotaped

client stimuli. Similarly, using a large sample, 71

females and 102 males, of master's level practicing

counselors responding via multiple choice answers to

videotaped client role plays, Petro and Hansen (1977)

found an equivalence of cognitive empathic judgments

between the genders. Contradictory results were found by

Sweeney and Cottle (1976) in their comparison of

counselors' and noncounselors' ability to accurately judge